the information contained in the schedule is made ... · a4221 maint drug infus cath per wk $22.26...

PT 33 DME Fee Sched 05-06-09 ds 1 of 62

Revised on May 8, 2009

CPT codes, descriptions and other data only are copyright © 2008 American Medical Association. All

rights reserved. Applicable FARS/DFARS apply. CPT is a registered trademark ® of the American

Medical Association.

Medicaid Service Manaul

HCPCS

Code

Short Description

(refer to a HIPAA-compliant HCPCS Book for current, full

descriptions)

Modifier RateRate Begin

DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A4206 1 CC STERILE SYRINGE&NEEDLE $0.39 09/01/08 02 01/01/05 60 units / rolling MO

A4208 3 CC STERILE SYRINGE&NEEDLE $0.39 09/01/08 00 01/01/85 30 units / MO

A4209 5+ CC STERILE SYRINGE&NEEDLE $0.40 07/01/06 02 01/01/05 30 units / MO

A4213 20+ CC SYRINGE ONLY $0.79 07/01/06 00 01/01/85 30 units / MO

A4216 STERILE WATER/SALINE, 10 ML $0.45 01/01/04 00 01/01/04

A4217 STERILE WATER/SALINE, 500 ML $2.66 01/01/04 00 01/01/04

A4218 STERILE SALINE OR WATER $4.75 09/01/08 00 01/01/06

A4221 MAINT DRUG INFUS CATH PER WK $22.26 01/01/80 00 01/01/97 15 units / MO

A4222 INFUSION SUPPLIES WITH PUMP $44.17 01/01/80 00 01/01/97

A4223 INFUSION SUPPLIES W/O PUMP $0.00 01/01/05 00 01/01/05

A4230 INFUS INSULIN PUMP NON NEEDL $10.07 09/01/08 02 07/01/07 15 units / MO

A4231 INFUSION INSULIN PUMP NEEDLE $5.10 09/01/08 02 07/01/07 15 units / MO

A4232 SYRINGE W/NEEDLE INSULIN 3CC $2.61 01/01/80 00 01/01/96 15 units / MO

A4244 ALCOHOL OR PEROXIDE PER PINT $0.79 07/01/06 00 01/01/85 3 units / MO

A4245 ALCOHOL WIPES PER BOX $2.37 07/01/06 00 01/01/85 3 units / 2 MO

A4246 BETADINE/PHISOHEX SOLUTION $2.77 07/01/06 00 01/01/85 3 units / MO

A4248 CHLORHEXIDINE ANTISEPT $1.73 09/01/08 00 01/01/04

A4280 BRST PRSTHS ADHSV ATTCHMNT $4.84 01/01/80 00 01/01/00

A4305 DRUG DELIVERY SYSTEM >=50 ML $13.41 03/01/05 00 01/01/93

A4306 DRUG DELIVERY SYSTEM <=50 ML $18.54 03/01/05 00 01/01/93

A4310 INSERT TRAY W/O BAG/CATH $7.72 01/01/80 02 01/01/04 2 units / MO

A4311 CATHETER W/O BAG 2-WAY LATEX $14.84 01/01/80 02 01/01/04

2. Providers must use the appropriate HCPCS code. For medically necessary DMEPOS items that do not appear on this list please refer to

Medicaid Services Manual, Chapter 1300, see link below.

Provider Type 33, Durable Medical Equipment, Prosthetics, Orthotics & Supplies

DMEPOS FEE SCHEDULE

The information contained in the schedule is made available to provide information and is not a

guarantee by the State or the Department or its employees as to the present accuracy of the

information contained herein. For example, coverage as well as an actual rate may have been

revised or updated and may no longer be the same as posted on the website.

Notes: 1. HCPCS codes with a rate of $0.00 are reimbursed at 62% of Usual and Customary charges unless noted otherwise in Nevada Medicaid policy.

http://dhcfp.nv.gov/MSM Table of Contents.htm?Accept


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A4312 CATH W/O BAG 2-WAY SILICONE $18.04 01/01/80 02 01/01/04

A4313 CATHETER W/BAG 3-WAY $18.52 01/01/80 02 01/01/04 2 units / MO

A4314 CATH W/DRAINAGE 2-WAY LATEX $21.50 01/01/80 02 01/01/04 2 units / MO

A4315 CATH W/DRAINAGE 2-WAY SILCNE $26.39 01/01/80 02 01/01/04 2 units / MO

A4316 CATH W/DRAINAGE 3-WAY $28.40 01/01/80 02 01/01/04 2 units / MO

A4320 IRRIGATION TRAY $5.33 01/01/80 00 01/01/90 60 units / MO

A4322 IRRIGATION SYRINGE $3.04 01/01/80 00 01/01/90 4 units / MO

A4326 MALE EXTERNAL CATHETER $10.79 01/01/80 00 01/01/90 10 units / MO

A4327 FEM URINARY COLLECT DEV CUP $42.27 01/01/80 00 01/01/90 2 units / MO

A4328 FEM URINARY COLLECT POUCH $10.45 01/01/80 00 01/01/90 2 units / MO

A4330 STOOL COLLECTION POUCH $7.15 01/01/80 00 01/01/90 4 units / MO

A4331 EXTENSION DRAINAGE TUBING $3.18 01/01/80 00 01/01/01 5 units / MO

A4332 LUBE STERILE PACKET $0.12 01/01/80 00 01/01/01

A4333 URINARY CATH ANCHOR DEVICE $2.20 01/01/80 00 01/01/01

A4334 URINARY CATH LEG STRAP $4.93 01/01/80 00 01/01/01

A4338 INDWELLING CATHETER LATEX $12.26 01/01/80 02 01/01/04 2 units / MO

A4340 INDWELLING CATHETER SPECIAL $26.99 01/01/80 02 01/01/04 2 units / MO

A4344 CATH INDW FOLEY 2 WAY SILICN $16.02 01/01/80 02 01/01/04 2 units / MO

A4346 CATH INDW FOLEY 3 WAY $19.25 01/01/80 02 01/01/04 3 units / MO

A4349 DISPOSABLE MALE EXTERNAL CAT $2.02 01/01/05 00 01/01/05

A4351 STRAIGHT TIP URINE CATHETER $1.81 01/01/80 02 01/01/04 30 units / MO

A4352 COUDE TIP URINARY CATHETER $6.42 01/01/80 02 01/01/04 30 units / MO

A4353 INTERMITTENT URINARY CATH $7.00 01/01/80 02 01/01/04 2 units / MO

A4354 CATH INSERTION TRAY W/BAG $11.80 01/01/80 02 01/01/04 2 units / MO

A4355 BLADDER IRRIGATION TUBING $7.86 01/01/80 00 01/01/84 1 unit / 2 MO

A4356 EXT URETH CLMP OR COMPR DVC $39.33 01/01/80 00 01/01/85 1 unit / 6 MO

A4357 BEDSIDE DRAINAGE BAG $9.70 01/01/80 00 01/01/85 2 units / MO

A4358 URINARY LEG OR ABDOMEN BAG $6.63 01/01/80 00 01/01/85 2 units / MO

A4361 OSTOMY FACE PLATE $18.37 01/01/80 00 01/01/85 1 unit / 2 MO

A4362 SOLID SKIN BARRIER $3.46 01/01/80 00 01/01/85 6 units / MO

A4363 OSTOMY CLAMP, REPLACEMENT $2.20 07/01/06 00 01/01/06

A4364 ADHESIVE, LIQUID OR EQUAL $2.93 01/01/80 00 01/01/85 1 unit / MO

A4365 ADHESIVE REMOVER WIPES $11.32 01/01/80 00 01/01/97 1 unit / MO

A4366 OSTOMY VENT $1.30 01/01/04 00 01/01/04 15 units / MO

A4367 OSTOMY BELT $7.35 01/01/80 00 01/01/85 2 units / MO

A4368 OSTOMY FILTER $0.26 01/01/80 00 01/01/97

A4369 SKIN BARRIER LIQUID PER OZ $2.06 01/01/80 00 01/01/00 4 units / MO

A4371 SKIN BARRIER POWDER PER OZ $3.60 01/01/80 00 01/01/00 1 unit / MO

A4372 SKIN BARRIER SOLID 4X4 EQUIV $4.18 01/01/80 00 01/01/00 15 units / MO

A4373 SKIN BARRIER WITH FLANGE $6.28 01/01/80 00 01/01/00 15 units / MO


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A4375 DRAINABLE PLASTIC PCH W FCPL $17.18 01/01/80 00 01/01/00 15 units / MO

A4376 DRAINABLE RUBBER PCH W FCPLT $47.58 01/01/80 00 01/01/00 15 units / MO

A4377 DRAINABLE PLSTIC PCH W/O FP $4.29 01/01/80 02 06/01/06 10 units / MO

A4378 DRAINABLE RUBBER PCH W/O FP $30.75 01/01/80 02 06/01/06 10 units / MO

A4379 URINARY PLASTIC POUCH W FCPL $15.02 01/01/80 02 06/01/06 10 units / MO

A4380 URINARY RUBBER POUCH W FCPLT $37.33 01/01/80 02 06/01/06 10 units / MO

A4381 URINARY PLASTIC POUCH W/O FP $4.61 01/01/80 02 06/01/06 10 units / MO

A4382 URINARY HVY PLSTC PCH W/O FP $24.62 01/01/80 02 06/01/06 10 units / MO

A4383 URINARY RUBBER POUCH W/O FP $28.19 01/01/80 02 06/01/06 10 units / MO

A4384 OSTOMY FACEPLT/SILICONE RING $9.62 01/01/80 00 01/01/00

A4385 OST SKN BARRIER SLD EXT WEAR $5.10 01/01/80 00 01/01/00 15 units / MO

A4387 OST CLSD POUCH W ATT ST BARR $0.00 03/01/05 02 03/01/05

A4388 DRAINABLE PCH W EX WEAR BARR $4.36 01/01/80 00 01/01/00 60 units / MO

A4389 DRAINABLE PCH W ST WEAR BARR $6.22 01/01/80 00 01/01/00 60 units / MO

A4390 DRAINABLE PCH EX WEAR CONVEX $9.61 01/01/80 00 01/01/00 60 units / MO

A4391 URINARY POUCH W EX WEAR BARR $7.07 01/01/80 00 01/01/00 30 units / MO

A4392 URINARY POUCH W ST WEAR BARR $8.18 01/01/80 00 01/01/00 30 units / MO

A4393 URINE PCH W EX WEAR BAR CONV $9.04 01/01/80 00 01/01/00 30 units / MO

A4394 OSTOMY POUCH LIQ DEODORANT $2.58 01/01/80 00 01/01/00 16 units / MO

A4395 OSTOMY POUCH SOLID DEODORANT $0.05 01/01/80 00 01/01/00 30 units / MO

A4396 PERISTOMAL HERNIA SUPPRT BLT $40.48 01/01/80 00 01/01/01 2 units / YR

A4397 IRRIGATION SUPPLY SLEEVE $4.07 01/01/80 00 01/01/90 1 unit/ 2 MO

A4398 OSTOMY IRRIGATION BAG $13.81 01/01/80 00 01/01/89 2 units / 6 MO

A4399 OSTOMY IRRIG CONE/CATH W BRS $12.26 01/01/80 00 01/01/89 1 unit / 6 MO

A4400 OSTOMY IRRIGATION SET $48.87 01/01/80 00 01/01/82 1 unit / 6 MO

A4402 LUBRICANT PER OUNCE $1.60 01/01/80 00 01/01/85 4 units / MO

A4404 OSTOMY RING EACH $1.63 01/01/80 02 06/01/06 10 units / MO

A4405 NONPECTIN BASED OSTOMY PASTE $3.40 01/01/80 00 01/01/03 4 units / MO

A4406 PECTIN BASED OSTOMY PASTE $5.74 01/01/80 00 01/01/03 4 units / MO

A4407 EXT WEAR OST SKN BARR <=4SQ� $8.76 01/01/80 00 01/01/03 20 units / MO

A4408 EXT WEAR OST SKN BARR >4SQ� $9.87 01/01/80 00 01/01/03 20 units / MO

A4409 OST SKN BARR CONVEX <=4 SQ I $6.22 01/01/80 00 01/01/03 30 units / MO

A4410 OST SKN BARR EXTND >4 SQ $9.04 01/01/80 00 01/01/03 3 units / 2 MO

A4411 OST SKN BARR EXTND =4SQ $5.10 07/01/06 00 01/01/06 20 units / MO

A4412 OST POUCH DRAIN HIGH OUTPUT $2.70 07/01/06 00 01/01/06 20 units / MO

A4413 2 PC DRAINABLE OST POUCH $5.50 01/01/80 00 01/01/03 20 units / MO

A4414 OST SKNBAR W/O CONV<=4 SQ IN $4.93 01/01/80 00 01/01/03 20 units / MO

A4415 OST SKN BARR W/O CONV >4 SQI $6.00 01/01/80 00 01/01/03 20 units / MO

A4416 OST PCH CLSD W BARRIER/FILTR $2.75 01/01/04 00 01/01/04 60 units / MO

A4417 OST PCH W BAR/BLTINCONV/FLTR $3.72 01/01/04 00 01/01/04 60 units / MO


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A4418 OST PCH CLSD W/O BAR W FILTR $1.81 01/01/04 00 01/01/04 60 units / MO

A4419 OST PCH FOR BAR W FLANGE/FLT $1.74 01/01/04 00 01/01/04 60 units / MO

A4420 OST PCH CLSD FOR BAR W LK FL $0.00 01/01/04 00 01/01/04 60 units / MO

A4422 OST POUCH ABSORBENT MATERIAL $0.12 01/01/80 00 01/01/03 31 units / MO

A4423 OST PCH FOR BAR W LK FL/FLTR $1.86 01/01/04 00 01/01/04 60 units / MO

A4424 OST PCH DRAIN W BAR & FILTER $4.75 01/01/04 00 01/01/04 20 units / MO

A4425 OST PCH DRAIN FOR BARRIER FL $3.58 01/01/04 00 01/01/04 20 units / MO

A4426 OST PCH DRAIN 2 PIECE SYSTEM $2.73 01/01/04 00 01/01/04 20 units / MO

A4427 OST PCH DRAIN/BARR LK FLNG/F $2.78 01/01/04 00 01/01/04 20 units / MO

A4428 URINE OST POUCH W FAUCET/TAP $6.51 01/01/04 00 01/01/04 15 units / MO

A4429 URINE OST POUCH W BLTINCONV $8.25 01/01/04 00 01/01/04 20 units / MO

A4430 OST URINE PCH W B/BLTIN CONV $8.52 01/01/04 00 01/01/04 15 units / MO

A4431 OST PCH URINE W BARRIER/TAPV $6.22 01/01/04 00 01/01/04 20 units / MO

A4432 OS PCH URINE W BAR/FANGE/TAP $3.59 01/01/04 00 01/01/04 20 units / MO

A4433 URINE OST PCH BAR W LOCK FLN $3.34 01/01/04 00 01/01/04 20 units / MO

A4434 OST PCH URINE W LOCK FLNG/FT $3.76 01/01/04 00 01/01/04 20 units / MO

A4450 NON-WATERPROOF TAPE $0.09 01/01/80 00 01/01/03 40 units / MO

A4452 WATERPROOF TAPE $0.36 01/01/80 00 01/01/03 40 units / MO

A4455 ADHESIVE REMOVER PER OUNCE $1.22 01/01/80 00 01/01/89 1 unit / 2 MO

A4461 SURGICL DRESS HOLD NON-REUSE $3.29 01/01/07 00 01/01/07

A4463 SURGICAL DRESS HOLDER REUSE $0.00 01/01/07 00 01/01/07

A4481 TRACHEOSTOMA FILTER $0.38 01/01/80 00 01/01/97

A4483 MOISTURE EXCHANGER $0.00 01/01/99 00 01/01/99

A4490 ABOVE KNEE SURGICAL STOCKING $5.93 07/01/06 00 01/01/86 2 units / 6 MO

A4495 THIGH LENGTH SURG STOCKING $5.93 07/01/06 00 01/01/86 2 units / 6 MO

A4500 BELOW KNEE SURGICAL STOCKING $4.35 07/01/06 00 01/01/86 2 units / 6 MO

A4510 FULL LENGTH SURG STOCKING $10.67 07/01/06 00 01/01/86 2 units / 6 MO

A4554 DISPOSABLE UNDERPADS $0.40 01/01/07 0 - 2 yrs 01 01/01/03 300 units / MO

A4554 DISPOSABLE UNDERPADS $0.40 01/01/07 3 yrs + 02 01/01/86 300 units / MO

A4556 ELECTRODES, PAIR $12.14 01/01/80 00 01/01/84 15 units / MO

A4557 LEAD WIRES, PAIR $17.94 01/01/80 00 01/01/84 2 units / MO

A4558 CONDUCTIVE GEL OR PASTE $5.45 01/01/80 00 01/01/85

A4559 COUPLING GEL OR PASTE $0.00 01/01/07 00 01/01/07

A4565 SLINGS $6.32 07/01/06 00 01/01/83 2 units / 12 MO

A4601 LITH ION BATT NON-PROS USE $0.00 01/01/07 00 01/01/07

A4604 TUBING WITH HEATING ELEMENT NU $66.81 07/01/06 01 01/01/06

A4605 TRACH SUCTION CATH CLOSE SYS NU $16.40 01/01/05 00 01/01/05

A4608 TRANSTRACHEAL OXYGEN CATH $58.15 01/01/80 00 01/01/01

A4611 HEAVY DUTY BATTERY NU $166.98 01/01/80 00 01/01/90

A4611 HEAVY DUTY BATTERY RR $20.37 01/01/80 00 01/01/90


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A4611 HEAVY DUTY BATTERY UE $125.24 01/01/80 00 01/01/90

A4612 BATTERY CABLES NU $79.93 01/01/80 01 01/01/90 1 unit / 6 MO

A4612 BATTERY CABLES RR $8.14 01/01/80 01 01/01/90 1 unit / 6 MO

A4612 BATTERY CABLES UE $60.95 01/01/80 01 01/01/90 1 unit / 6 MO

A4613 BATTERY CHARGER NU $144.21 01/01/80 01 01/01/90 1 unit / 36 MO (RR excluded)

A4613 BATTERY CHARGER RR $14.43 01/01/80 01 01/01/90

A4613 BATTERY CHARGER UE $104.29 01/01/80 01 01/01/90 1 unit / 36 MO (RR excluded)

A4614 HAND-HELD PEFR METER $23.78 01/01/80 00 01/01/99 1 unit / 6 MO

A4618 BREATHING CIRCUITS NU $7.56 01/01/80 00 01/01/90 15 units / MO

A4618 BREATHING CIRCUITS RR $1.02 01/01/80 00 01/01/90 15 units / MO

A4618 BREATHING CIRCUITS UE $5.67 01/01/80 00 01/01/90 15 units / MO

A4619 FACE TENT $1.21 01/01/80 00 01/01/90 5 units / MO

A4620 VARIABLE CONCENTRATION MASK $2.37 07/01/06 00 01/01/90 5 units / MO

A4623 TRACHEOSTOMY INNER CANNULA $5.57 01/01/80 00 01/01/90 2 units / MO

A4624 TRACHEAL SUCTION TUBE NU $2.63 01/01/80 00 01/01/90

A4625 TRACH CARE KIT FOR NEW TRACH $6.58 01/01/80 00 01/01/90 50 units / MO

A4626 TRACHEOSTOMY CLEANING BRUSH $2.78 01/01/80 00 01/01/90

A4627 SPACER BAG/RESERVOIR $15.02 07/01/06 00 01/01/91 1 unit / 12 MO

A4628 OROPHARYNGEAL SUCTION CATH NU $3.65 01/01/80 00 01/01/96 5 units / MO

A4629 TRACHEOSTOMY CARE KIT $4.61 01/01/80 00 01/01/96

A4635 UNDERARM CRUTCH PAD NU $4.35 01/01/80 00 01/01/91

A4635 UNDERARM CRUTCH PAD RR $0.69 01/01/80 00 01/01/91

A4635 UNDERARM CRUTCH PAD UE $2.88 01/01/80 00 01/01/91

A4636 HANDGRIP FOR CANE ETC NU $3.58 01/01/80 00 01/01/91

A4636 HANDGRIP FOR CANE ETC RR $0.43 01/01/80 00 01/01/91

A4636 HANDGRIP FOR CANE ETC UE $2.61 01/01/80 00 01/01/91

A4637 REPL TIP CANE/CRUTCH/WALKER NU $1.81 01/01/80 00 01/01/91

A4637 REPL TIP CANE/CRUTCH/WALKER RR $0.30 01/01/80 00 01/01/91

A4637 REPL TIP CANE/CRUTCH/WALKER UE $1.37 01/01/80 00 01/01/91

A4638 REPL BATT PULSE GEN SYS $0.00 01/01/04 00 01/01/04

A4640 ALTERNATING PRESSURE PAD NU $53.82 01/01/80 00 01/01/91

A4640 ALTERNATING PRESSURE PAD RR $6.45 01/01/80 00 01/01/91

A4640 ALTERNATING PRESSURE PAD UE $38.13 01/01/80 00 01/01/91

A4649 SURGICAL SUPPLIES $0.00 01/01/82 00 01/01/82 10 dressing kits/central cath

A4660 SPHYG/BP APP W CUFF AND STET $50.00 01/01/80 00 01/01/86 1 unit / 36 MO

A4670 AUTOMATIC BP MONITOR, DIAL $50.00 01/01/80 00 01/01/86 1 unit / 2YR

A4673 EXT LINE W EASY LOCK CONNECT $0.00 01/01/04 00 01/01/04

A4927 NON-STERILE GLOVES, per 100 $9.69 01/01/80 00 01/01/86 8 units / MO

A4930 STERILE, GLOVES PER PAIR $0.47 01/01/80 00 01/01/03 20 units / MO

A5051 POUCH CLSD W BARR ATTACHED $2.07 01/01/80 00 01/01/90 60 units / MO


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A5052 CLSD OSTOMY POUCH W/O BARR $1.49 01/01/80 00 01/01/90 60 units / MO

A5053 CLSD OSTOMY POUCH FACEPLATE $1.48 01/01/80 00 01/01/90 60 units / MO

A5054 CLSD OSTOMY POUCH W/FLANGE $1.79 01/01/80 00 01/01/90 60 units / MO

A5055 STOMA CAP $1.44 01/01/80 00 01/01/90 31 units / MO

A5061 POUCH DRAINABLE W BARRIER AT $3.52 01/01/80 00 01/01/90 15 units / MO

A5062 DRNBLE OSTOMY POUCH W/O BARR $2.09 01/01/80 00 01/01/90 30 units / MO

A5063 DRAIN OSTOMY POUCH W/FLANGE $2.17 01/01/80 00 01/01/90 10 units / MO

A5071 URINARY POUCH W/BARRIER $6.01 01/01/80 00 01/01/90 15 units / MO

A5072 URINARY POUCH W/O BARRIER $3.43 01/01/80 00 01/01/90 15 units / MO

A5073 URINARY POUCH ON BARR W/FLNG $3.18 01/01/80 00 01/01/90 10 units / MO

A5081 CONTINENT STOMA PLUG $2.81 01/01/80 00 01/01/90 31 units / MO

A5082 CONTINENT STOMA CATHETER $10.11 01/01/80 00 01/01/90 1 unit / MO

A5083 Stoma absorptive cover $0.00 01/01/08 02 01/01/08 20 units / MO

A5093 OSTOMY ACCESSORY CONVEX INSE $1.95 01/01/80 02 06/01/06 10 units / MO

A5102 BEDSIDE DRAIN BTL W/WO TUBE $20.69 01/01/80 00 01/01/90 1 unit / 2 MO

A5105 URINARY SUSPENSORY $40.76 01/01/80 00 01/01/90 1 unit / MO

A5112 URINARY LEG BAG $34.62 01/01/80 00 01/01/90 1 unit / MO

A5113 LATEX LEG STRAP $4.70 01/01/80 00 01/01/90 1 unit / MO

A5114 FOAM/FABRIC LEG STRAP $8.94 01/01/80 00 01/01/90 1 unit / MO

A5120 SKIN BARRIER, WIPE OR SWAB $0.20 01/01/06 00 01/01/06 20 units / MO

A5120 SKIN BARRIER, WIPE OR SWAB AU $0.20 01/01/06 00 01/01/06 20 units / MO

A5120 SKIN BARRIER, WIPE OR SWAB AV $0.20 01/01/06 00 01/01/06 20 units / MO

A5121 SOLID SKIN BARRIER 6X6 $6.72 01/01/80 00 01/01/90 15 units / MO

A5122 SOLID SKIN BARRIER 8X8 $12.85 01/01/80 00 01/01/90 3 units / MO

A5126 DISK/FOAM PAD +OR- ADHESIVE $1.32 01/01/80 00 01/01/90 20 units / MO

A5131 APPLIANCE CLEANER $13.76 01/01/80 00 01/01/90 3 units / MO

A5200 PERCUTANEOUS CATHETER ANCHOR $11.29 01/01/80 00 01/01/99

A5500 DIAB SHOE FOR DENSITY INSERT $59.36 07/01/06 00 01/01/95 1 unit per foot per CAL YR

A5501 DIABETIC CUSTOM MOLDED SHOE $178.04 07/01/06 00 01/01/95

A5503 DIABETIC SHOE W/ROLLER/ROCKR $26.40 07/01/06 00 01/01/95

A5504 DIABETIC SHOE WITH WEDGE $26.40 07/01/06 00 01/01/95

A5505 DIAB SHOE W/METATARSAL BAR $26.40 07/01/06 00 01/01/95

A5506 DIABETIC SHOE W/OFF SET HEEL $26.40 07/01/06 00 01/01/95

A5507 MODIFICATION DIABETIC SHOE $26.40 07/01/06 00 01/01/95

A5508 DIABETIC DELUXE SHOE $0.00 01/01/00 00 01/01/00

A5510 COMPRESSION FORM SHOE INSERT $0.00 01/01/02 00 01/01/02

A5512 MULTI DEN INSERT DIRECT FORM $24.22 01/01/06 00 01/01/06

A5513 FOR DIABETICS ONLY, MULTIPLE DENSIT $36.14 01/01/06 00 01/01/06 1 unit per foot per MO; max 6 units per YR

A6010 COLLAGEN BASED WOUND FILLER $30.96 01/01/80 00 01/01/02


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A6011 COLLAGEN GEL/PASTE WOUND FIL $2.28 01/01/80 00 01/01/03

A6021 COLLAGEN DRESSING <=16 SQ IN $21.02 01/01/80 00 01/01/01

A6022 COLLAGEN DRSG>6<=48 SQ IN $21.02 01/01/80 00 01/01/01

A6023 COLLAGEN DRESSING >48 SQ IN $190.30 01/01/80 00 01/01/01

A6024 COLLAGEN DSG WOUND FILLER $6.19 01/01/80 00 01/01/01

A6025 SILICONE GEL SHEET, EACH $21.71 07/01/06 00 01/01/97

A6154 WOUND POUCH EACH $14.36 01/01/80 00 01/01/97

A6196 ALGINATE DRESSING <=16 SQ IN $7.35 01/01/80 00 01/01/97

A6197 ALGINATE DRSG >16 <=48 SQ IN $16.44 01/01/80 00 01/01/97

A6199 ALGINATE DRSG WOUND FILLER $5.29 01/01/80 00 01/01/97

A6200 COMPOS DRSG <=16 NO BORDER $9.50 01/01/80 00 01/01/99

A6201 COMPOS DRSG >16<=48 NO BDR $20.80 01/01/80 00 01/01/99 180 units / MO

A6202 COMPOS DRSG >48 NO BORDER $34.88 01/01/80 00 01/01/99 180 units / MO

A6203 COMPOSITE DRSG <= 16 SQ IN $3.35 01/01/80 00 01/01/97

A6204 COMPOSITE DRSG >16<=48 SQ IN $6.23 01/01/80 00 01/01/97

A6207 CONTACT LAYER >16<= 48 SQ IN $7.34 01/01/80 00 01/01/97

A6209 FOAM DRSG <=16 SQ IN W/O BDR $7.48 01/01/80 00 01/01/97

A6210 FOAM DRG >16<=48 SQ IN W/O B $19.92 01/01/80 00 01/01/97 30 units / MO

A6211 FOAM DRG > 48 SQ IN W/O BRDR $29.37 01/01/80 00 01/01/97

A6212 FOAM DRG <=16 SQ IN W/BORDER $9.70 01/01/80 00 01/01/97

A6214 FOAM DRG > 48 SQ IN W/BORDER $10.29 01/01/80 00 01/01/97

A6216 NON-STERILE GAUZE<=16 SQ IN $0.05 01/01/80 00 01/01/97 60 units / MO

A6219 GAUZE <= 16 SQ IN W/BORDER $0.95 01/01/80 00 01/01/97

A6220 GAUZE >16 <=48 SQ IN W/BORDR $2.58 01/01/80 00 01/01/97

A6222 GAUZE <=16 IN NO W/SAL W/O B $2.13 01/01/80 00 01/01/97 3 units / MO

A6223 GAUZE >16<=48 NO W/SAL W/O B $2.42 01/01/80 00 01/01/97

A6224 GAUZE > 48 IN NO W/SAL W/O B $3.61 01/01/80 00 01/01/97

A6229 GAUZE >16<=48 SQ IN WATR/SAL $3.61 01/01/80 00 01/01/97

A6231 HYDROGEL DSG<=16 SQ IN $4.68 01/01/80 00 01/01/01

A6232 HYDROGEL DSG>16<=48 SQ IN $6.88 01/01/80 00 01/01/01

A6233 HYDROGEL DRESSING >48 SQ IN $19.19 01/01/80 00 01/01/01

A6234 HYDROCOLLD DRG <=16 W/O BDR $6.54 01/01/80 00 01/01/97

A6235 HYDROCOLLD DRG >16<=48 W/O B $16.82 01/01/80 00 01/01/97

A6236 HYDROCOLLD DRG > 48 IN W/O B $27.25 01/01/80 00 01/01/97

A6237 HYDROCOLLD DRG <=16 IN W/BDR $7.91 01/01/80 00 01/01/97

A6238 HYDROCOLLD DRG >16<=48 W/BDR $22.79 01/01/80 00 01/01/97

A6240 HYDROCOLLD DRG FILLER PASTE $12.24 01/01/80 00 01/01/97

A6241 HYDROCOLLOID DRG FILLER DRY $2.57 01/01/80 00 01/01/97

A6242 HYDROGEL DRG <=16 IN W/O BDR $6.07 01/01/80 00 01/01/97

A6243 HYDROGEL DRG >16<=48 W/O BDR $12.31 01/01/80 00 01/01/97


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A6244 HYDROGEL DRG >48 IN W/O BDR $39.28 01/01/80 00 01/01/97

A6245 HYDROGEL DRG <= 16 IN W/BDR $7.27 01/01/80 00 01/01/97

A6246 HYDROGEL DRG >16<=48 IN W/B $9.92 01/01/80 00 01/01/97

A6247 HYDROGEL DRG > 48 SQ IN W/B $23.78 01/01/80 00 01/01/97

A6248 HYDROGEL DRSG GEL FILLER $16.24 01/01/80 00 01/01/97 4 units / MO

A6251 ABSORPT DRG <=16 SQ IN W/O B $1.99 01/01/80 00 01/01/97 15 units / MO

A6252 ABSORPT DRG >16 <=48 W/O BDR $3.25 01/01/80 00 01/01/97

A6253 ABSORPT DRG > 48 SQ IN W/O B $6.34 01/01/80 00 01/01/97

A6254 ABSORPT DRG <=16 SQ IN W/BDR $1.21 01/01/80 00 01/01/97

A6255 ABSORPT DRG >16<=48 IN W/BDR $3.03 01/01/80 00 01/01/97

A6257 TRANSPARENT FILM <= 16 SQ IN $1.53 01/01/80 00 01/01/97

A6258 TRANSPARENT FILM >16<=48 IN $4.30 01/01/80 00 01/01/97

A6259 TRANSPARENT FILM > 48 SQ IN $10.94 01/01/80 00 01/01/97

A6261 WOUND FILLER GEL/PASTE /OZ $3.56 07/01/06 00 01/01/97

A6266 IMPREG GAUZE NO H20/SAL/YARD $1.92 01/01/80 00 01/01/97 10 units / MO

A6402 STERILE GAUZE <= 16 SQ IN $0.12 01/01/80 00 01/01/97

A6403 STERILE GAUZE>16 <= 48 SQ IN $0.43 01/01/80 00 01/01/97

A6407 PACKING STRIPS, NON-IMPREG $1.88 01/01/04 00 01/01/04

A6410 STERILE EYE PAD $0.39 01/01/80 00 01/01/03

A6441 PAD BAND W>=3� <5�/YD $0.67 01/01/04 00 01/01/04

A6442 CONFORM BAND N/S W<3�/YD $0.17 01/01/04 00 01/01/04

A6443 CONFORM BAND N/S W>=3�<5�/YD $0.29 01/01/04 00 01/01/04

A6444 CONFORM BAND N/S W>=5�/YD $0.56 01/01/04 00 01/01/04

A6445 CONFORM BAND S W <3�/YD $0.32 01/01/04 00 01/01/04

A6446 CONFORM BAND S W>=3� <5�/YD $0.41 01/01/04 00 01/01/04

A6447 CONFORM BAND S W >=5�/YD $0.67 01/01/04 00 01/01/04

A6448 LT COMPRES BAND <3�/YD $1.16 01/01/04 00 01/01/04

A6449 LT COMPRES BAND >=3� <5�/YD $1.75 01/01/04 00 01/01/04

A6450 LT COMPRES BAND >=5�/YD $0.00 01/01/04 00 01/01/04

A6451 MOD COMPRES BAND W>=3�<5�/YD $0.00 01/01/04 00 01/01/04

A6452 HIGH COMPRES BAND W>=3�<5�YD $5.91 01/01/04 00 01/01/04

A6453 SELF-ADHER BAND W <3�/YD $0.61 01/01/04 00 01/01/04

A6454 SELF-ADHER BAND W>=3� <5�/YD $0.77 01/01/04 00 01/01/04

A6455 SELF-ADHER BAND >=5�/YD $1.39 01/01/04 00 01/01/04

A6456 ZINC PASTE BAND W >=3> $1.28 01/01/04 00 01/01/04 2 units / MO

A6457 TUBULAR DRESSING $1.14 01/01/06 00 01/01/06

A6501 COMPRES BURNGARMENT BODYSUIT NU $0.00 01/01/03 01 06/01/07

A6502 COMPRES BURNGARMENT CHINSTRP NU $0.00 01/01/03 01 06/01/07

A6503 COMPRES BURNGARMENT FACEHOOD NU $0.00 01/01/03 01 06/01/07

A6504 CMPRSBURNGARMENT GLOVE-WRIST NU $0.00 01/01/03 01 06/01/07


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A6505 CMPRSBURNGARMENT GLOVE-ELBOW NU $0.00 01/01/03 01 06/01/07

A6506 CMPRSBURNGRMNT GLOVE-AXILLA NU $0.00 01/01/03 01 06/01/07

A6507 CMPRS BURNGARMENT FOOT-KNEE NU $0.00 01/01/03 01 06/01/07

A6508 CMPRS BURNGARMENT FOOT-THIGH NU $0.00 01/01/03 01 06/01/07

A6509 COMPRES BURN GARMENT JACKET NU $0.00 01/01/03 01 06/01/07

A6510 COMPRES BURN GARMENT LEOTARD NU $0.00 01/01/03 00 04/01/03

A6511 COMPRES BURN GARMENT PANTY NU $0.00 01/01/03 01 06/01/07

A6512 COMPRES BURN GARMENT, NOC NU $0.00 01/01/03 01 06/01/07

A6513 COMPRESS BURN MASK FACE/NECK $0.00 01/01/06 01 01/01/06

A6530 COMPRESSION STOCKING BK18-30 $25.00 01/01/06 00 01/01/06 1 unit per leg per 6 MO

A6531 COMPRESSION STOCKING BK30-40 $43.27 01/01/06 00 01/01/06

A6532 COMPRESSION STOCKING BK40-50 $60.96 01/01/06 00 01/01/06

A6533 GC STOCKING THIGHLNGTH 18-30 $30.00 01/01/06 00 01/01/06



A6536 GC STOCKING FULL LNGTH 18-30 $40.00 01/01/06 00 01/01/06



A6539 GC STOCKING WAISTLNGTH 18-30 $80.00 01/01/06 00 01/01/06



A6542 GC STOCKING CUSTOM MADE $0.00 01/01/06 01 01/01/06

A6543 GC STOCKING LYMPHEDEMA $10.00 01/01/06 00 01/01/06

A6544 GC STOCKING GARTER BELT $14.00 01/01/06 00 01/01/06

A6545 GRAD COMP NN-ELASTIC BK $0.00 01/01/09 00 01/01/09

A6549 G COMPRESSION STOCKING $0.00 01/01/06 01 01/01/06

A6550 NEG PRES WOUND THER DRSG SET $27.42 01/01/04 00 01/01/04

A7000 DISPOSABLE CANISTER FOR PUMP NU $9.54 01/01/80 00 01/01/00 10 units / MO

A7001 NONDISPOSABLE PUMP CANISTER NU $33.08 01/01/80 00 01/01/00

A7002 TUBING USED W SUCTION PUMP NU $3.83 01/01/80 00 01/01/00 5 units / MO

A7003 NEBULIZER ADMINISTRATION SET NU $2.74 01/01/80 00 01/01/00

A7004 DISPOSABLE NEBULIZER SML VOL NU $1.80 01/01/80 00 01/01/00 5 units / MO

A7005 NONDISPOSABLE NEBULIZER SET NU $30.83 01/01/80 00 01/01/00 2 units / 12 MO

A7006 FILTERED NEBULIZER ADMIN SET NU $9.54 01/01/80 00 01/01/00

A7009 NEBULIZER RESERVOIR BOTTLE NU $42.04 01/01/80 00 01/01/00 30 units / MO

A7010 DISPOSABLE CORRUGATED TUBING NU $23.59 01/01/80 00 01/01/00

A7012 NEBULIZER WATER COLLEC DEVIC NU $3.78 01/01/80 00 01/01/00 10 units / MO

A7013 DISPOSABLE COMPRESSOR FILTER NU $0.83 01/01/80 00 01/01/00 12 units / 12 MO

A7014 COMPRESSOR NONDISPOS FILTER NU $4.49 01/01/80 00 01/01/00

A7015 AEROSOL MASK USED W NEBULIZE NU $1.88 01/01/80 00 01/01/00 4 units / MO


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A7016 NEBULIZER DOME & MOUTHPIECE NU $7.25 01/01/80 00 01/01/00

A7017 NEBULIZER NOT USED W OXYGEN NU $134.04 01/01/80 00 01/01/00

A7017 NEBULIZER NOT USED W OXYGEN RR $13.40 01/01/80 00 01/01/00

A7017 NEBULIZER NOT USED W OXYGEN UE $100.52 01/01/80 00 01/01/00

A7018 WATER DISTILLED W/NEBULIZER $0.38 01/01/80 00 01/01/01 15 units / MO

A7025 REPLACE CHEST COMPRESS VEST NU $434.94 01/01/80 01 01/01/03

A7026 REPLACE CHST CMPRSS SYS HOSE NU $28.75 01/01/80 01 01/01/03

A7027 Combination oral/nasal mask NU $179.35 01/01/08 00 01/01/08

A7028 Repl oral cushion combo mask NU $49.54 01/01/08 00 01/01/08

A7029 Repl nasal pillow comb mask NU $20.24 01/01/08 00 01/01/08

A7030 CPAP FULL FACE MASK NU $188.64 01/01/80 00 01/01/03

A7031 REPLACEMENT FACEMASK INTERFA NU $69.77 01/01/80 00 01/01/03

A7032 REPLACEMENT NASAL CUSHION NU $40.53 01/01/80 00 01/01/03

A7033 REPLACEMENT NASAL PILLOWS NU $28.41 01/01/80 00 01/01/03

A7034 NASAL APPLICATION DEVICE NU $117.64 01/01/80 00 01/01/03

A7035 POS AIRWAY PRESS HEADGEAR NU $39.75 01/01/80 00 01/01/03

A7036 POS AIRWAY PRESS CHINSTRAP NU $18.20 01/01/80 00 01/01/03

A7037 POS AIRWAY PRESSURE TUBING NU $41.02 01/01/80 00 01/01/03

A7038 POS AIRWAY PRESSURE FILTER NU $5.39 01/01/80 00 01/01/03

A7039 FILTER, NON DISPOSABLE W PAP NU $15.33 01/01/80 00 01/01/03

A7040 ONE WAY CHEST DRAIN VALVE $36.86 01/01/05 00 01/01/05

A7041 WATER SEAL DRAIN CONTAINER $69.26 01/01/05 00 01/01/05

A7044 PAP ORAL INTERFACE NU $120.91 01/01/80 00 01/01/03

A7045 REPL EXHALATION PORT FOR PAP NU $19.47 01/01/05 00 01/01/05

A7045 REPL EXHALATION PORT FOR PAP RR $1.95 01/01/05 00 01/01/05

A7045 REPL EXHALATION PORT FOR PAP UE $14.60 01/01/05 00 01/01/05

A7046 REPL WATER CHAMBER, PAP DEV $19.51 01/01/04 00 01/01/04

A7501 TRACHEOSTOMA VALVE W DIAPHRA $105.03 01/01/80 00 01/01/01

A7502 REPLACEMENT DIAPHRAGM/FPLATE $49.91 01/01/80 00 01/01/01

A7503 HMES FILTER HOLDER OR CAP $11.33 01/01/80 00 01/01/01

A7504 TRACHEOSTOMA HMES FILTER $0.67 01/01/80 00 01/01/01

A7505 HMES OR TRACH VALVE HOUSING $4.68 01/01/80 00 01/01/01

A7506 HMES/TRACHVALVE ADHESIVEDISK $0.33 01/01/80 00 01/01/01

A7507 INTEGRATED FILTER & HOLDER $2.49 01/01/80 00 01/01/01

A7508 HOUSING & INTEGRATED ADHESIV $2.87 01/01/80 00 01/01/01

A7509 HEAT & MOISTURE EXCHANGE SYS $1.41 01/01/80 00 01/01/01

A7520 TRACH/LARYN TUBE NON-CUFFED $47.48 01/01/04 00 01/01/04

A7521 TRACH/LARYN TUBE CUFFED $47.05 01/01/04 00 01/01/04

A7522 TRACH/LARYN TUBE STAINLESS $45.16 01/01/04 00 01/01/04

A7524 TRACHEOSTOMA STENT/STUD/BTTN $77.40 01/01/04 00 01/01/04


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

A7525 TRACHEOSTOMY MASK $2.07 01/01/04 00 01/01/04

A7526 TRACHEOSTOMY TUBE COLLAR $3.37 01/01/04 00 01/01/04

A7527 TRACH/LARYN TUBE PLUG/STOP $3.58 01/01/05 00 01/01/05

A8000 SOFT PROTECT HELMET PREFAB NU $153.35 01/01/07 00 01/01/07

A8000 SOFT PROTECT HELMET PREFAB RR $15.33 01/01/07 00 01/01/07

A8000 SOFT PROTECT HELMET PREFAB UE $115.03 01/01/07 00 01/01/07

A8001 HARD PROTECT HELMET PREFAB NU $153.35 01/01/07 00 01/01/07

A8001 HARD PROTECT HELMET PREFAB RR $15.33 01/01/07 00 01/01/07

A8001 HARD PROTECT HELMET PREFAB UE $115.03 01/01/07 00 01/01/07

A8002 SOFT PROTECT HELMET CUSTOM NU $0.00 01/01/07 01 01/01/07

A8002 SOFT PROTECT HELMET CUSTOM RR $0.00 01/01/07 01 01/01/07

A8002 SOFT PROTECT HELMET CUSTOM UE $0.00 01/01/07 01 01/01/07

A8003 HARD PROTECT HELMET CUSTOM NU $0.00 01/01/07 01 01/01/07

A8003 HARD PROTECT HELMET CUSTOM RR $0.00 01/01/07 01 01/01/07

A8003 HARD PROTECT HELMET CUSTOM UE $0.00 01/01/07 01 01/01/07

A8004 REPL SOFT INTERFACE HELMET NU $0.00 01/01/07 00 01/01/07

A8004 REPL SOFT INTERFACE HELMET RR $0.00 01/01/07 00 01/01/07

A8004 REPL SOFT INTERFACE HELMET UE $0.00 01/01/07 00 01/01/07

A9900 SUPPLY/ACCESSORY/SERVICE $0.00 01/01/01 01 12/01/07 300 units / MO

A9999 DME SUPPLY OR ACCESSORY, NOS $0.00 01/01/04 01 12/01/07 300 units / MO

B4034 ENTER FEED SUPKIT SYR BY DAY $5.66 01/01/80 00 09/01/03

B4035 ENTERAL FEED SUPP PUMP PER D $10.79 01/01/80 00 01/01/86 31 units / MO

B4036 ENTERAL FEED SUP KIT GRAV BY $7.39 01/01/80 00 09/01/03 30 units / MO

B4081 ENTERAL NG TUBING W/ STYLET $20.00 01/01/80 00 01/01/86

B4082 ENTERAL NG TUBING W/O STYLET $14.89 01/01/80 00 01/01/86 4 units / MO

B4083 ENTERAL STOMACH TUBE LEVINE $2.27 01/01/80 00 01/01/86 4 units / MO

B4087 Gastro/jejuno tube std $38.22 01/01/08 02 01/01/08 1 unit / 3 MO

B4088 Gastro/jejuno tube low-pro BA $112.80 01/01/08 02 01/01/08 1 unit / 3 MO

B4102 EF ADULT FLUIDS AND ELECTRO $0.00 01/01/05 21 yrs + 02 01/01/05

B4103 EF PED FLUID AND ELECTROLYTE $0.00 01/01/05 0 - 20 yrs 02 01/01/05

B4104 ADDITIVE FOR ENTERAL FORMULA $2.15 06/01/08 02 01/01/05

B4149 EF BLENDERIZED FOODS $1.53 01/01/05 02 01/01/05

B4150 EF COMPLET W/INTACT NUTRIENT $0.62 01/01/80 01 10/01/03

B4152 EF CALORIE DENSE>/=1.5KCAL $0.52 01/01/80 01 10/01/03

B4153 EF HYDROLYZED/AMINO ACIDS $1.86 01/01/05 01 10/01/03

B4154 EF SPEC METABOLIC NONINHERIT $1.15 10/01/04 01 10/01/03

B4155 EF INCOMPLETE/MODULAR $0.88 01/01/80 01 10/01/03

B4157 EF SPECIAL METABOLIC INHERIT $7.01 06/01/08 02 01/01/05

B4158 EF PED COMPLETE INTACT NUT $1.37 06/01/08 0 - 20 yrs 02 01/01/05


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

B4159 EF PED COMPLETE SOY BASED $1.63 06/01/08 0 - 20 yrs 02 01/01/05

B4160 EF PED CALORIC DENSE>/=0.7KC $1.51 06/01/08 0 - 20 yrs 02 01/01/05

B4161 EF PED HYDROLYZED/AMINO ACID $3.27 06/01/08 0 - 20 yrs 02 01/01/05

B4162 EF PED SPECMETABOLIC INHERIT $0.00 01/01/05 0 - 20 yrs 02 01/01/05

B4220 PARENTERAL SUPPLY KIT PREMIX $7.18 01/01/80 00 01/01/84

B4222 PARENTERAL SUPPLY KIT HOMEMI $8.85 01/01/80 00 01/01/86

B4224 PARENTERAL ADMINISTRATION KI $22.43 01/01/80 00 01/01/86

B9000 ENTER INFUSION PUMP W/O ALRM NU $1,134.31 01/01/80 01 01/01/88

B9000 ENTER INFUSION PUMP W/O ALRM RR $104.23 01/01/80 01 01/01/88

B9000 ENTER INFUSION PUMP W/O ALRM UE $850.73 01/01/80 01 01/01/88

B9002 ENTERAL INFUSION PUMP W/ ALA NU $1,134.31 01/01/80 01 01/01/88

B9002 ENTERAL INFUSION PUMP W/ ALA RR $109.86 01/01/80 01 01/01/88

B9002 ENTERAL INFUSION PUMP W/ ALA UE $850.73 01/01/80 01 01/01/88

B9004 PARENTERAL INFUS PUMP PORTAB NU $2,262.63 01/01/80 01 01/01/88

B9004 PARENTERAL INFUS PUMP PORTAB RR $358.20 01/01/80 01 01/01/88

B9004 PARENTERAL INFUS PUMP PORTAB UE $1,696.97 01/01/80 01 01/01/88

B9006 PARENTERAL INFUS PUMP STATIO NU $2,262.63 01/01/80 01 01/01/88

B9006 PARENTERAL INFUS PUMP STATIO RR $358.20 01/01/80 01 01/01/88

B9006 PARENTERAL INFUS PUMP STATIO UE $1,696.97 01/01/80 01 01/01/88

B9998 ENTERAL SUPP NOT OTHERWISE C $0.00 11/01/01 00 01/01/85 4 units / MO

E0100 CANE ADJUST/FIXED WITH TIP NU $21.07 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0100 CANE ADJUST/FIXED WITH TIP RR $5.94 01/01/80 00 01/01/86

E0100 CANE ADJUST/FIXED WITH TIP UE $16.80 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0105 CANE ADJUST/FIXED QUAD/3 PRO NU $49.11 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0105 CANE ADJUST/FIXED QUAD/3 PRO RR $8.86 01/01/80 00 01/01/86

E0105 CANE ADJUST/FIXED QUAD/3 PRO UE $37.86 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0110 CRUTCH FOREARM PAIR NU $65.95 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0110 CRUTCH FOREARM PAIR RR $15.99 01/01/80 00 01/01/86

E0110 CRUTCH FOREARM PAIR UE $49.45 01/01/80 00 01/01/86

E0111 CRUTCH FOREARM EACH NU $45.27 01/01/80 00 01/01/86 2 units / 36 MO

E0111 CRUTCH FOREARM EACH RR $8.43 01/01/80 00 01/01/86 2 units / 36 MO

E0111 CRUTCH FOREARM EACH UE $34.94 01/01/80 00 01/01/86 2 units / 36 MO

E0112 CRUTCH UNDERARM PAIR WOOD NU $33.11 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0112 CRUTCH UNDERARM PAIR WOOD RR $9.93 01/01/80 00 01/01/86

E0112 CRUTCH UNDERARM PAIR WOOD UE $24.85 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0113 CRUTCH UNDERARM EACH WOOD NU $17.96 01/01/80 00 01/01/86 2 units / 36 MO

E0113 CRUTCH UNDERARM EACH WOOD RR $5.15 01/01/80 00 01/01/86 2 units / 36 MO

E0113 CRUTCH UNDERARM EACH WOOD UE $13.48 01/01/80 00 01/01/86 2 units / 36 MO

E0114 CRUTCH UNDERARM PAIR NO WOOD NU $40.11 01/01/80 00 01/01/86 1 unit / 24 MO


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0114 CRUTCH UNDERARM PAIR NO WOOD RR $8.57 01/01/80 00 01/01/86 1 unit / 24 MO

E0114 CRUTCH UNDERARM PAIR NO WOOD UE $30.32 01/01/80 00 01/01/86 1 unit / 24 MO

E0116 CRUTCH UNDERARM EACH NO WOOD NU $23.58 01/01/80 00 01/01/86 2 units / 36 MO

E0116 CRUTCH UNDERARM EACH NO WOOD RR $5.40 01/01/80 00 01/01/86 2 units / 36 MO

E0116 CRUTCH UNDERARM EACH NO WOOD UE $17.75 01/01/80 00 01/01/86 2 units / 36 MO

E0117 UNDERARM SPRINGASSIST CRUTCH NU $192.71 01/01/80 00 01/01/03

E0117 UNDERARM SPRINGASSIST CRUTCH RR $19.26 01/01/80 00 01/01/03

E0117 UNDERARM SPRINGASSIST CRUTCH UE $144.55 01/01/80 00 01/01/03

E0118 CRUTCH SUBSTITUTE NU $334.00 11/01/07 01 07/01/07

E0118 CRUTCH SUBSTITUTE RR $33.40 11/01/07 01 07/01/07

E0130 WALKER RIGID ADJUST/FIXED HT NU $70.23 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0130 WALKER RIGID ADJUST/FIXED HT RR $16.82 01/01/80 00 01/01/86

E0130 WALKER RIGID ADJUST/FIXED HT UE $54.73 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0135 WALKER FOLDING ADJUST/FIXED NU $83.84 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0135 WALKER FOLDING ADJUST/FIXED RR $17.26 01/01/80 00 01/01/86

E0135 WALKER FOLDING ADJUST/FIXED UE $64.32 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0140 WALKER W TRUNK SUPPORT NU $360.71 01/01/04 01 01/01/04 1 unit / 36 MO (RR excluded) + UVSP =1

E0140 WALKER W TRUNK SUPPORT RR $36.08 01/01/04 01 01/01/04

E0140 WALKER W TRUNK SUPPORT UE $270.54 01/01/04 01 01/01/04 1 unit / 36 MO (RR excluded) + UVSP =1

E0141 RIGID WHEELED WALKER ADJ/FIX NU $114.74 01/01/80 00 01/01/86

E0141 RIGID WHEELED WALKER ADJ/FIX RR $22.36 01/01/80 00 01/01/86

E0141 RIGID WHEELED WALKER ADJ/FIX UE $86.07 01/01/80 00 01/01/86

E0143 WALKER FOLDING WHEELED W/O S NU $120.23 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0143 WALKER FOLDING WHEELED W/O S RR $21.59 01/01/80 00 01/01/86

E0143 WALKER FOLDING WHEELED W/O S UE $89.98 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0148 HEAVYDUTY WALKER NO WHEELS NU $127.05 01/01/80 01 01/01/01

E0148 HEAVYDUTY WALKER NO WHEELS RR $12.72 01/01/80 01 01/01/01

E0148 HEAVYDUTY WALKER NO WHEELS UE $95.28 01/01/80 01 01/01/01

E0149 HEAVY DUTY WHEELED WALKER NU $223.20 01/01/80 01 01/01/01

E0149 HEAVY DUTY WHEELED WALKER RR $22.32 01/01/80 01 01/01/01

E0149 HEAVY DUTY WHEELED WALKER UE $167.39 01/01/80 01 01/01/01

E0153 FOREARM CRUTCH PLATFORM ATTA NU $69.38 01/01/80 00 01/01/86

E0153 FOREARM CRUTCH PLATFORM ATTA RR $7.84 01/01/80 00 01/01/86

E0153 FOREARM CRUTCH PLATFORM ATTA UE $52.03 01/01/80 00 01/01/86

E0154 WALKER PLATFORM ATTACHMENT NU $70.51 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0154 WALKER PLATFORM ATTACHMENT RR $8.56 01/01/80 00 01/01/86

E0154 WALKER PLATFORM ATTACHMENT UE $53.57 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0155 WALKER WHEEL ATTACHMENT,PAIR NU $26.83 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0155 WALKER WHEEL ATTACHMENT,PAIR RR $3.85 01/01/80 00 01/01/86

E0155 WALKER WHEEL ATTACHMENT,PAIR UE $20.44 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0157 WALKER CRUTCH ATTACHMENT NU $81.92 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0157 WALKER CRUTCH ATTACHMENT RR $8.99 01/01/80 00 01/01/86

E0157 WALKER CRUTCH ATTACHMENT UE $61.45 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0158 WALKER LEG EXTENDERS SET OF4 NU $27.35 01/01/80 00 01/01/86 4 units / 36 MO

E0158 WALKER LEG EXTENDERS SET OF4 RR $3.55 01/01/80 00 01/01/86 4 units / 36 MO

E0158 WALKER LEG EXTENDERS SET OF4 UE $20.65 01/01/80 00 01/01/86 4 units / 36 MO

E0159 BRAKE FOR WHEELED WALKER NU $17.87 01/01/80 00 01/01/97

E0159 BRAKE FOR WHEELED WALKER RR $1.80 01/01/80 00 01/01/97

E0159 BRAKE FOR WHEELED WALKER UE $13.40 01/01/80 00 01/01/97

E0163 COMMODE CHAIR WITH FIXED ARM NU $110.03 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0163 COMMODE CHAIR WITH FIXED ARM RR $24.43 01/01/80 00 01/01/86

E0163 COMMODE CHAIR WITH FIXED ARM UE $82.52 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0165 COMMODE CHAIR WITH DETACHARM NU $183.10 01/01/07 02 01/01/07 1 unit / 36 MO (RR excluded)

E0165 COMMODE CHAIR WITH DETACHARM RR $18.31 01/01/80 02 01/01/07

E0165 COMMODE CHAIR WITH DETACHARM UE $137.33 01/01/07 02 01/01/07 1 unit / 36 MO (RR excluded)

E0167 COMMODE CHAIR PAIL OR PAN NU $12.00 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0167 COMMODE CHAIR PAIL OR PAN RR $1.26 01/01/80 00 01/01/86

E0167 COMMODE CHAIR PAIL OR PAN UE $9.04 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0168 HEAVYDUTY/WIDE COMMODE CHAIR NU $150.92 01/01/80 01 01/01/01 2 units / 6 MO

E0168 HEAVYDUTY/WIDE COMMODE CHAIR RR $15.09 01/01/80 01 01/01/01 2 units / 6 MO

E0168 HEAVYDUTY/WIDE COMMODE CHAIR UE $113.18 01/01/80 01 01/01/01 2 units / 6 MO

E0181 PRESS PAD ALTERNATING W/ PUM NU $228.80 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0181 PRESS PAD ALTERNATING W/ PUM RR $22.88 01/01/80 01 01/01/86

E0182 REPLACE PUMP, ALT PRESS PAD NU $261.80 01/01/80 01 01/01/86

E0182 REPLACE PUMP, ALT PRESS PAD RR $26.18 01/01/80 01 01/01/86

E0184 DRY PRESSURE MATTRESS NU $165.50 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0184 DRY PRESSURE MATTRESS RR $20.88 01/01/80 00 01/01/86

E0184 DRY PRESSURE MATTRESS UE $126.92 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0185 GEL PRESSURE MATTRESS PAD NU $271.88 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0185 GEL PRESSURE MATTRESS PAD RR $38.20 01/01/80 00 01/01/86

E0185 GEL PRESSURE MATTRESS PAD UE $208.66 01/01/80 00 01/01/86 1 unit / 36 MO (RR excluded)

E0186 AIR PRESSURE MATTRESS NU $203.00 01/01/80 01 01/01/86 1 unit / 24 MO

E0186 AIR PRESSURE MATTRESS RR $20.30 01/01/80 01 01/01/86

E0187 WATER PRESSURE MATTRESS NU $232.10 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0187 WATER PRESSURE MATTRESS RR $23.21 01/01/80 01 01/01/86

E0191 PROTECTOR HEEL OR ELBOW NU $8.49 01/01/80 00 01/01/86 2 units / 3 MO

E0191 PROTECTOR HEEL OR ELBOW RR $1.02 01/01/80 00 01/01/86 2 units / 3 MO

E0191 PROTECTOR HEEL OR ELBOW UE $6.34 01/01/80 00 01/01/86 2 units / 3 MO


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0193 POWERED AIR FLOTATION BED RR $868.50 01/01/80 01 01/01/90

E0194 AIR FLUIDIZED BED RR $3,254.34 01/01/80 01 01/01/91

E0196 GEL PRESSURE MATTRESS NU $276.20 01/01/80 01 01/01/91

E0196 GEL PRESSURE MATTRESS RR $27.62 01/01/80 01 01/01/91

E0197 AIR PRESSURE PAD FOR MATTRES NU $219.18 01/01/80 00 01/01/91 1 unit / 36 MO (RR excluded)

E0197 AIR PRESSURE PAD FOR MATTRES RR $25.98 01/01/80 00 01/01/91

E0197 AIR PRESSURE PAD FOR MATTRES UE $165.44 01/01/80 00 01/01/91 1 unit / 36 MO (RR excluded)

E0198 WATER PRESSURE PAD FOR MATTR NU $219.18 01/01/80 00 01/01/91

E0198 WATER PRESSURE PAD FOR MATTR RR $21.91 01/01/80 00 01/01/91

E0198 WATER PRESSURE PAD FOR MATTR UE $164.39 01/01/80 00 01/01/91

E0199 DRY PRESSURE PAD FOR MATTRES NU $32.05 01/01/80 00 01/01/91 1 unit / 2 MO

E0199 DRY PRESSURE PAD FOR MATTRES RR $3.19 01/01/80 00 01/01/91 1 unit / 2 MO

E0199 DRY PRESSURE PAD FOR MATTRES UE $24.04 01/01/80 00 01/01/91 1 unit / 2 MO

E0202 PHOTOTHERAPY LIGHT W/ PHOTOM RR 53.76/day 01/01/80 00 01/01/85 3 units (days) / cal YR

E0240 BATH/SHOWER CHAIR NU $45.00 01/01/04 00 01/01/04

E0241 BATH TUB WALL RAIL NU $20.00 04/01/03 00 04/01/03

E0242 BATH TUB RAIL FLOOR NU $20.00 04/01/03 00 04/01/03

E0243 TOILET RAIL NU $20.00 04/01/03 00 04/01/03

E0244 TOILET SEAT RAISED $45.00 01/01/80 02 05/01/07 1 unit / 36 MO

E0245 TUB STOOL OR BENCH NU $80.00 01/01/86 02 05/01/07 1 unit / 36 MO

E0246 TRANSFER TUB RAIL ATTACHMENT NU $20.00 04/01/03 02 04/01/03 1 unit / 36 MO

E0247 TRANS BENCH W/WO COMM OPEN $80.00 01/01/04 00 01/01/04

E0248 HDTRANS BENCH W/WO COMM OPEN $100.00 01/01/04 01 01/01/04

E0250 HOSP BED FIXED HT W/ MATTRES NU $586.56 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E0250 HOSP BED FIXED HT W/ MATTRES RR $97.76 01/01/80 01 01/01/86

E0251 HOSP BED FIXD HT W/O MATTRES NU $444.48 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E0251 HOSP BED FIXD HT W/O MATTRES RR $74.08 01/01/80 01 01/01/86

E0255 HOSPITAL BED VAR HT W/ MATTR NU $704.88 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E0255 HOSPITAL BED VAR HT W/ MATTR RR $117.48 01/01/80 01 01/01/86

E0256 HOSPITAL BED VAR HT W/O MATT NU $500.10 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0256 HOSPITAL BED VAR HT W/O MATT RR $83.35 01/01/80 01 01/01/91

E0260 HOSP BED SEMI-ELECTR W/ MATT NU $1,007.58 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E0260 HOSP BED SEMI-ELECTR W/ MATT RR $167.93 01/01/80 01 01/01/86

E0261 HOSP BED SEMI-ELECTR W/O MAT NU $821.64 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0261 HOSP BED SEMI-ELECTR W/O MAT RR $136.94 01/01/80 01 01/01/91

E0265 HOSP BED TOTAL ELECTR W/ MAT NU $1,019.40 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E0265 HOSP BED TOTAL ELECTR W/ MAT RR $169.90 01/01/80 01 01/01/86

E0266 HOSP BED TOTAL ELEC W/O MATT NU $1,065.54 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E0266 HOSP BED TOTAL ELEC W/O MATT RR $177.59 01/01/80 01 01/01/86

E0271 MATTRESS INNERSPRING NU $222.04 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0271 MATTRESS INNERSPRING RR $23.06 01/01/80 01 01/01/86

E0271 MATTRESS INNERSPRING UE $173.46 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E0272 MATTRESS FOAM RUBBER NU $202.37 01/01/80 01 01/01/86

E0272 MATTRESS FOAM RUBBER RR $21.13 01/01/80 01 01/01/86

E0272 MATTRESS FOAM RUBBER UE $151.05 01/01/80 01 01/01/86

E0275 BED PAN STANDARD NU $13.35 01/01/80 00 01/01/86 1 unit / 12 MO

E0275 BED PAN STANDARD RR $1.60 01/01/80 00 01/01/86

E0275 BED PAN STANDARD UE $10.03 01/01/80 00 01/01/86 1 unit / 12 MO

E0276 BED PAN FRACTURE NU $11.31 01/01/80 00 01/01/86 1 unit / 12 MO

E0276 BED PAN FRACTURE RR $1.57 01/01/80 00 01/01/86

E0276 BED PAN FRACTURE UE $8.94 01/01/80 00 01/01/86 1 unit / 12 MO

E0277 POWERED PRES-REDU AIR MATTRS NU $3,872.76 01/01/80 01 01/01/92 1 unit / 60 MO (RR excluded)

E0277 POWERED PRES-REDU AIR MATTRS RR $645.46 01/01/80 01 01/01/92

E0280 BED CRADLE NU $32.48 01/01/80 00 01/01/86 1 unit / 36 MO

E0280 BED CRADLE RR $4.11 01/01/80 00 01/01/86

E0280 BED CRADLE UE $24.35 01/01/80 00 01/01/86 1 unit / 36 MO

E0290 HOSP BED FX HT W/O RAILS W/M NU $448.44 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0290 HOSP BED FX HT W/O RAILS W/M RR $74.74 01/01/80 01 01/01/91

E0291 HOSP BED FX HT W/O RAIL W/O NU $325.80 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0291 HOSP BED FX HT W/O RAIL W/O RR $54.30 01/01/80 01 01/01/91

E0292 HOSP BED VAR HT W/O RAIL W/O NU $504.24 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0292 HOSP BED VAR HT W/O RAIL W/O RR $84.04 01/01/80 01 01/01/91

E0293 HOSP BED VAR HT W/O RAIL W/ NU $429.06 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0293 HOSP BED VAR HT W/O RAIL W/ RR $71.51 01/01/80 01 01/01/91

E0294 HOSP BED SEMI-ELECT W/ MATTR NU $783.90 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0294 HOSP BED SEMI-ELECT W/ MATTR RR $130.65 01/01/80 01 01/01/91

E0295 HOSP BED SEMI-ELECT W/O MATT NU $764.10 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0295 HOSP BED SEMI-ELECT W/O MATT RR $127.35 01/01/80 01 01/01/91

E0296 HOSP BED TOTAL ELECT W/ MATT NU $837.42 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0296 HOSP BED TOTAL ELECT W/ MATT RR $139.57 01/01/80 01 01/01/91

E0297 HOSP BED TOTAL ELECT W/O MAT NU $844.02 01/01/80 01 01/01/91 1 unit / 60 MO (RR excluded)

E0297 HOSP BED TOTAL ELECT W/O MAT RR $140.67 01/01/80 01 01/01/91

E0300 ENCLOSED PED CRIB HOSP GRADE NU $2,838.62 01/01/04 01 01/01/04 1 unit / 60 MO (RR excluded) + UVSP = 1

E0300 ENCLOSED PED CRIB HOSP GRADE RR $283.86 01/01/04 01 01/01/04 UVSP = 1 unit

E0300 ENCLOSED PED CRIB HOSP GRADE UE $2,128.96 01/01/04 01 01/01/04 1 unit / 60 MO ( RR excluded) + UVSP = 1

E0301 HD HOSP BED, 350-600 LBS RR $256.30 01/01/04 01 01/01/04

E0302 EX HD HOSP BED > 600 LBS RR $715.44 01/01/04 01 01/01/04

E0303 HOSP BED HVY DTY XTRA WIDE RR $289.52 01/01/04 01 01/01/04


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0304 HOSP BED XTRA HVY DTY X WIDE RR $770.67 01/01/04 01 01/01/04

E0305 RAILS BED SIDE HALF LENGTH NU $106.74 01/01/80 01 01/01/86

E0305 RAILS BED SIDE HALF LENGTH RR $17.79 01/01/80 01 01/01/86

E0310 RAILS BED SIDE FULL LENGTH NU $194.14 01/01/80 01 01/01/86 2 units / 60 MO (RR excluded)

E0310 RAILS BED SIDE FULL LENGTH RR $21.09 01/01/80 01 01/01/86

E0310 RAILS BED SIDE FULL LENGTH UE $146.91 01/01/80 01 01/01/86 2 units / 60 MO (RR excluded)

E0316 BED SAFETY ENCLOSURE NU $1,116.00 01/01/80 01 01/01/02

E0316 BED SAFETY ENCLOSURE RR $186.00 01/01/80 01 01/01/02

E0325 URINAL MALE JUG-TYPE NU $8.59 01/01/80 00 01/01/86 1 unit / 12 MO

E0325 URINAL MALE JUG-TYPE RR $1.51 01/01/80 00 01/01/86

E0325 URINAL MALE JUG-TYPE UE $5.69 01/01/80 00 01/01/86 1 unit / 12 MO

E0326 URINAL FEMALE JUG-TYPE NU $8.93 01/01/80 00 01/01/86 1 unit / 12 MO

E0326 URINAL FEMALE JUG-TYPE RR $1.19 01/01/80 00 01/01/86

E0326 URINAL FEMALE JUG-TYPE UE $6.69 01/01/80 00 01/01/86 1 unit / 12 MO

E0328 Ped hospital bed manual $0.00 01/01/08 01 01/01/08 I unit / 60 MO

E0329 Ped hospital bed semi/elect $0.00 01/01/08 01 01/01/08 1 unit / 60 MO

E0371 NONPOWER MATTRESS OVERLAY NU $2,534.94 01/01/80 01 01/01/98 1 unit / 60 MO (RR excluded)

E0371 NONPOWER MATTRESS OVERLAY RR $422.49 01/01/80 01 01/01/98

E0372 POWERED AIR MATTRESS OVERLAY NU $3,075.84 01/01/80 01 01/01/98 1 unit / 60 MO (RR excluded)

E0372 POWERED AIR MATTRESS OVERLAY RR $512.64 01/01/80 01 01/01/98

E0373 NONPOWERED PRESSURE MATTRESS NU $3,523.56 01/01/80 01 01/01/98 1 unit / 60 MO (RR excluded)

E0373 NONPOWERED PRESSURE MATTRESS RR $587.26 01/01/80 01 01/01/98

E0424 STATIONARY COMPRESSED GAS 02 RR $228.80 01/01/80 01 01/01/93 372 units / 12 MO

E0430 OXYGEN SYSTEM GAS PORTABLE NU $215.82 01/01/86 01 01/01/86 372 units / 12 MO

E0431 PORTABLE GASEOUS 02 RR $35.97 01/01/80 01 01/01/93

E0439 STATIONARY LIQUID 02 RR $228.80 01/01/80 01 11/01/02

E0441 OXYGEN CONTENTS, GASEOUS $162.98 01/01/80 01 01/01/93

E0443 PORTABLE 02 CONTENTS, GAS $21.41 01/01/80 01 01/01/93 8 units / MO

E0444 PORTABLE 02 CONTENTS, LIQUID $21.41 01/01/80 01 01/01/93

E0445 OXIMETER NON-INVASIVE RR $199.50 10/01/03 01 10/01/03

E0450 VOL CONTROL VENT INVASIV INT RR $954.52 01/01/80 01 01/01/85 372 units / 12 MO

E0457 CHEST SHELL NU $614.51 01/01/80 01 01/01/90 186 units / cal YR

E0457 CHEST SHELL RR $61.45 01/01/80 01 01/01/90 186 units / cal YR

E0457 CHEST SHELL UE $460.85 01/01/80 01 01/01/90 186 units / cal YR

E0459 CHEST WRAP NU $508.90 01/01/80 01 01/01/90

E0459 CHEST WRAP RR $50.89 01/01/80 01 01/01/90

E0460 NEG PRESS VENT PORTABL/STATN RR $623.53 01/01/80 01 01/01/90

E0461 VOL CONTROL VENT NONINV INT RR $1,002.05 01/01/80 01 01/01/03 372 units / 12 MO

E0462 ROCKING BED W/ OR W/O SIDE R NU $1,748.40 01/01/80 01 01/01/90

E0462 ROCKING BED W/ OR W/O SIDE R RR $291.40 01/01/80 01 01/01/90


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0463 PRESS SUPP VENT INVASIVE INT RR $2,800.00 01/01/05 01 01/01/05

E0464 PRESS SUPP VENT NONINV INT RR $1,406.38 01/01/05 01 01/01/05

E0470 RAD W/O BACKUP NON-INV INTFC NU $2,181.10 01/01/04 01 01/01/04

E0470 RAD W/O BACKUP NON-INV INTFC RR $218.11 01/01/04 01 01/01/04

E0471 RAD W/BACKUP NON INV INTRFC RR $642.17 01/01/04 01 01/01/04

E0472 RAD W BACKUP INVASIVE INTRFC RR $642.17 01/01/04 01 01/01/04

E0480 PERCUSSOR ELECT/PNEUM HOME M NU $439.40 01/01/80 01 01/01/86

E0480 PERCUSSOR ELECT/PNEUM HOME M RR $43.94 01/01/80 01 01/01/86

E0482 COUGH STIMULATING DEVICE NU $4,087.60 01/01/80 01 01/01/02

E0482 COUGH STIMULATING DEVICE RR $408.76 01/01/80 01 01/01/02

E0483 CHEST COMPRESSION GEN SYSTEM NU $10,631.30 01/01/80 01 01/01/03

E0483 CHEST COMPRESSION GEN SYSTEM RR $1,063.13 01/01/80 01 01/01/03

E0484 NON-ELEC OSCILLATORY PEP DVC NU $36.92 01/01/80 01 01/01/03

E0484 NON-ELEC OSCILLATORY PEP DVC RR $3.69 01/01/80 01 01/01/03

E0484 NON-ELEC OSCILLATORY PEP DVC UE $27.70 01/01/80 01 01/01/03

E0500 IPPB ALL TYPES RR $108.19 01/01/80 01 01/01/86

E0550 HUMIDIF EXTENS SUPPLE W IPPB NU $501.30 01/01/80 01 01/01/86

E0550 HUMIDIF EXTENS SUPPLE W IPPB RR $50.13 01/01/80 01 01/01/86

E0560 HUMIDIFIER SUPPLEMENTAL W/ I NU $171.52 01/01/80 01 01/01/86

E0560 HUMIDIFIER SUPPLEMENTAL W/ I RR $20.10 01/01/80 01 01/01/86

E0560 HUMIDIFIER SUPPLEMENTAL W/ I UE $128.64 01/01/80 01 01/01/86

E0561 HUMIDIFIER NONHEATED W PAP NU $107.00 01/01/04 01 01/01/04

E0561 HUMIDIFIER NONHEATED W PAP RR $10.69 01/01/04 01 01/01/04

E0561 HUMIDIFIER NONHEATED W PAP UE $80.24 01/01/04 01 01/01/04

E0562 HUMIDIFIER HEATED USED W PAP NU $301.22 01/01/04 01 01/01/04

E0562 HUMIDIFIER HEATED USED W PAP RR $30.11 01/01/04 01 01/01/04

E0562 HUMIDIFIER HEATED USED W PAP UE $225.91 01/01/04 01 01/01/04

E0565 COMPRESSOR AIR POWER SOURCE NU $518.60 01/01/80 01 01/01/82 1 unit / 36 MO (RR excluded)

E0565 COMPRESSOR AIR POWER SOURCE RR $51.86 01/01/80 01 01/01/82 93 units / YR

E0570 NEBULIZER WITH COMPRESSION NU $167.70 01/01/80 00 01/01/03

E0570 NEBULIZER WITH COMPRESSION RR $16.77 01/01/80 00 01/01/03

E0571 AEROSOL COMPRESSOR FOR SVNEB NU $286.40 01/01/80 01 01/01/01

E0571 AEROSOL COMPRESSOR FOR SVNEB RR $28.64 01/01/80 01 01/01/01

E0572 AEROSOL COMPRESSOR ADJUST PR NU $364.20 01/01/80 01 01/01/01

E0572 AEROSOL COMPRESSOR ADJUST PR RR $36.42 01/01/80 01 01/01/01

E0580 NEBULIZER FOR USE W/ REGULAT NU $134.04 01/01/80 01 01/01/86 1 unit / 6 MO

E0580 NEBULIZER FOR USE W/ REGULAT RR $13.40 01/01/80 01 01/01/86 1 unit / 6 MO

E0580 NEBULIZER FOR USE W/ REGULAT UE $100.52 01/01/80 01 01/01/86 1 unit / 6 MO

E0585 NEBULIZER W/ COMPRESSOR & HE NU $298.10 01/01/80 01 01/01/86

E0585 NEBULIZER W/ COMPRESSOR & HE RR $29.81 01/01/80 01 01/01/86


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0600 SUCTION PUMP PORTAB HOM MODL NU $325.47 01/01/80 00 01/01/86 2 units / 36 MO (RR excluded)

E0600 SUCTION PUMP PORTAB HOM MODL RR $43.33 01/01/80 00 01/01/86

E0601 CONT AIRWAY PRESSURE DEVICE NU $1,117.10 01/01/80 01 01/01/88

E0601 CONT AIRWAY PRESSURE DEVICE RR $111.71 01/01/80 01 01/01/88

E0606 DRAINAGE BOARD POSTURAL NU $229.40 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E0606 DRAINAGE BOARD POSTURAL RR $22.94 01/01/80 01 01/01/86

E0618 APNEA MONITOR RR $279.24 01/01/80 00 01/01/03

E0619 APNEA MONITOR W RECORDER RR $279.24 01/01/03 00 01/01/03

E0621 PATIENT LIFT SLING OR SEAT NU $95.99 01/01/80 01 01/01/86 1 unit / 24 MO

E0621 PATIENT LIFT SLING OR SEAT RR $9.25 01/01/80 01 01/01/86 1 unit / 24 MO

E0621 PATIENT LIFT SLING OR SEAT UE $72.36 01/01/80 01 01/01/86 1 unit / 24 MO

E0630 PATIENT LIFT HYDRAULIC NU $611.34 01/01/80 01 01/01/86

E0630 PATIENT LIFT HYDRAULIC RR $101.89 01/01/80 01 01/01/86

E0635 PATIENT LIFT ELECTRIC NU $734.16 01/01/80 01 01/01/86

E0635 PATIENT LIFT ELECTRIC RR $122.36 01/01/80 01 01/01/86

E0637 COMBINATION SIT TO STAND SYS NU $2,104.97 01/01/04 01 01/01/04

E0637 COMBINATION SIT TO STAND SYS RR $210.51 01/01/04 01 01/01/04

E0637 COMBINATION SIT TO STAND SYS UE $1,578.72 01/01/04 01 01/01/04

E0638 STANDING FRAME SYS NU $853.57 01/01/04 01 01/01/04

E0638 STANDING FRAME SYS RR $85.36 01/01/04 01 01/01/04

E0638 STANDING FRAME SYS UE $640.18 01/01/04 01 01/01/04

E0639 MOVEABLE PATIENT LIFT SYSTEM $0.00 01/01/05 01 01/01/05

E0640 FIXED PATIENT LIFT SYSTEM $0.00 01/01/05 01 01/01/05

E0650 PNEUMA COMPRESOR NON-SEGMENT NU $720.22 01/01/80 01 01/01/86 186 units / cal YR

E0650 PNEUMA COMPRESOR NON-SEGMENT RR $86.65 01/01/80 01 01/01/86 186 units / cal YR

E0650 PNEUMA COMPRESOR NON-SEGMENT UE $540.16 01/01/80 01 01/01/86 186 units / cal YR

E0651 PNEUM COMPRESSOR SEGMENTAL NU $907.14 01/01/80 01 01/01/88 1 unit / 36 MO

E0651 PNEUM COMPRESSOR SEGMENTAL RR $90.71 01/01/80 01 01/01/88 1 unit / 36 MO

E0651 PNEUM COMPRESSOR SEGMENTAL UE $680.36 01/01/80 01 01/01/88 1 unit / 36 MO

E0652 PNEUM COMPRES W/CAL PRESSURE NU $5,301.45 01/01/80 01 01/01/88 1 unit / 36 MO

E0652 PNEUM COMPRES W/CAL PRESSURE RR $523.95 01/01/80 01 01/01/88 1 unit / 36 MO

E0652 PNEUM COMPRES W/CAL PRESSURE UE $3,972.53 01/01/80 01 01/01/88 1 unit / 36 MO

E0655 PNEUMATIC APPLIANCE HALF ARM NU $107.92 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0655 PNEUMATIC APPLIANCE HALF ARM RR $12.68 01/01/80 01 01/01/86

E0655 PNEUMATIC APPLIANCE HALF ARM UE $81.05 01/01/80 01 01/01/86

E0656 SEGMENTAL PNEUMATIC TRUNK NU $0.00 01/01/09 01 01/01/09

E0656 SEGMENTAL PNEUMATIC TRUNK RR $0.00 01/01/09 01 01/01/09

E0656 SEGMENTAL PNEUMATIC TRUNK UE $0.00 01/01/09 01 01/01/09

E0657 SEGMENTAL PNEUMATIC CHEST NU $0.00 01/01/09 01 01/01/09

E0657 SEGMENTAL PNEUMATIC CHEST RR $0.00 01/01/09 01 01/01/09


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0657 SEGMENTAL PNEUMATIC CHEST UE $0.00 01/01/09 01 01/01/09

E0660 PNEUMATIC APPLIANCE FULL LEG NU $159.66 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0660 PNEUMATIC APPLIANCE FULL LEG RR $16.63 01/01/80 01 01/01/86

E0660 PNEUMATIC APPLIANCE FULL LEG UE $119.75 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0665 PNEUMATIC APPLIANCE FULL ARM NU $136.99 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0665 PNEUMATIC APPLIANCE FULL ARM RR $14.07 01/01/80 01 01/01/86

E0665 PNEUMATIC APPLIANCE FULL ARM UE $102.76 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0666 PNEUMATIC APPLIANCE HALF LEG NU $138.08 01/01/80 01 01/01/86

E0666 PNEUMATIC APPLIANCE HALF LEG RR $14.23 01/01/80 01 01/01/86

E0666 PNEUMATIC APPLIANCE HALF LEG UE $103.59 01/01/80 01 01/01/86

E0667 SEG PNEUMATIC APPL FULL LEG NU $323.77 01/01/80 01 01/01/88 1 unit / 36 MO

E0667 SEG PNEUMATIC APPL FULL LEG RR $36.56 01/01/80 01 01/01/88 1 unit / 36 MO

E0667 SEG PNEUMATIC APPL FULL LEG UE $242.83 01/01/80 01 01/01/88 1 unit / 36 MO

E0668 SEG PNEUMATIC APPL FULL ARM NU $441.88 01/01/80 01 01/01/88 1 unit / 36 MO

E0668 SEG PNEUMATIC APPL FULL ARM RR $43.61 01/01/80 01 01/01/88 1 unit / 36 MO

E0668 SEG PNEUMATIC APPL FULL ARM UE $331.42 01/01/80 01 01/01/88 1 unit / 36 MO

E0669 SEG PNEUMATIC APPLI HALF LEG NU $183.31 01/01/80 01 01/01/94

E0669 SEG PNEUMATIC APPLI HALF LEG RR $18.34 01/01/80 01 01/01/94

E0669 SEG PNEUMATIC APPLI HALF LEG UE $137.51 01/01/80 01 01/01/94

E0671 PRESSURE PNEUM APPL FULL LEG NU $415.35 01/01/80 01 01/01/95

E0671 PRESSURE PNEUM APPL FULL LEG RR $41.54 01/01/80 01 01/01/95

E0671 PRESSURE PNEUM APPL FULL LEG UE $311.50 01/01/80 01 01/01/95

E0672 PRESSURE PNEUM APPL FULL ARM NU $322.73 01/01/80 01 01/01/95

E0672 PRESSURE PNEUM APPL FULL ARM RR $32.28 01/01/80 01 01/01/95

E0672 PRESSURE PNEUM APPL FULL ARM UE $242.06 01/01/80 01 01/01/95

E0673 PRESSURE PNEUM APPL HALF LEG NU $268.17 01/01/80 01 01/01/95

E0673 PRESSURE PNEUM APPL HALF LEG RR $26.82 01/01/80 01 01/01/95

E0673 PRESSURE PNEUM APPL HALF LEG UE $201.15 01/01/80 01 01/01/95

E0675 PNEUMATIC COMPRESSION DEVICE RR $321.99 01/01/04 01 01/01/04

E0700 SAFETY EQUIPMENT NU $0.00 01/01/86 01 01/01/86

E0705 TRANSFER DEVICE NU $55.12 07/01/06 00 01/01/06

E0747 ELEC OSTEOGEN STIM NOT SPINE NU $3,527.21 01/01/80 01 01/01/86

E0747 ELEC OSTEOGEN STIM NOT SPINE RR $350.51 01/01/80 01 01/01/86

E0747 ELEC OSTEOGEN STIM NOT SPINE UE $2,620.65 01/01/80 01 01/01/86

E0748 ELEC OSTEOGEN STIM SPINAL NU $3,504.35 01/01/80 01 01/01/96

E0748 ELEC OSTEOGEN STIM SPINAL RR $350.43 01/01/80 01 01/01/96

E0748 ELEC OSTEOGEN STIM SPINAL UE $2,628.28 01/01/80 01 01/01/96

E0776 IV POLE NU $94.33 01/01/80 00 01/01/85 1 unit / 60 MO (RR excluded)

E0776 IV POLE RR $9.43 01/01/85 00 01/01/85

E0779 AMB INFUSION PUMP MECHANICAL NU $251.73 01/01/80 01 01/01/00


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0780 MECH AMB INFUSION PUMP <8HRS NU $10.37 01/01/80 01 01/01/00 93 units / YR

E0781 EXTERNAL AMBULATORY INFUS PU NU $2,517.30 01/01/80 01 01/01/87 93 units / YR

E0781 EXTERNAL AMBULATORY INFUS PU RR $251.73 01/01/80 01 01/01/87 93 units / YR

E0784 EXT AMB INFUSN PUMP INSULIN NU $4,174.90 01/01/05 3 yrs + 01 01/01/96 1 unit / 60 MO (RR excluded)

E0784 EXT AMB INFUSN PUMP INSULIN RR $417.49 01/01/80 3 yrs + 01 01/01/96 93 days / cal YR (NU excluded)

E0791 PARENTERAL INFUSION PUMP STA NU $3,162.00 01/01/80 01 01/01/89

E0791 PARENTERAL INFUSION PUMP STA RR $316.20 01/01/80 01 01/01/89

E0910 TRAPEZE BAR ATTACHED TO BED NU $200.00 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0910 TRAPEZE BAR ATTACHED TO BED RR $20.00 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0911 HD TRAPEZE BAR ATTACH TO BED RR $49.85 07/01/06 01 01/01/06

E0912 HD TRAPEZE BAR FREE STANDING RR $114.47 07/01/06 01 01/01/06

E0935 CONT PAS MOTION EXERCISE DEV RR 19.32/day 01/01/80 01 11/01/02 14 units / cal YR

E0936 CPM DEVICE OTHER THAN KNEE RR $0.00 01/01/07 01 01/01/07

E0940 TRAPEZE BAR FREE STANDING NU $347.70 01/01/80 01 01/01/86 1 unit / 36 MO (RR excluded)

E0940 TRAPEZE BAR FREE STANDING RR $34.77 01/01/80 01 01/01/86

E0951 LOOP HEEL NU $18.83 01/01/80 00 01/01/86 2 units / 24 MO

E0951 LOOP HEEL RR $1.95 01/01/80 00 01/01/86 2 units / 24 MO

E0951 LOOP HEEL UE $14.13 01/01/80 00 01/01/86 2 units / 24 MO

E0955 CUSHIONED HEADREST NU $202.18 01/01/04 01 01/01/04

E0955 CUSHIONED HEADREST RR $20.23 01/01/04 01 01/01/04

E0955 CUSHIONED HEADREST UE $151.63 01/01/04 01 01/01/04

E0956 W/C LATERAL TRUNK/HIP SUPPOR NU $98.56 01/01/04 01 01/01/04

E0956 W/C LATERAL TRUNK/HIP SUPPOR RR $9.87 01/01/04 01 01/01/04

E0956 W/C LATERAL TRUNK/HIP SUPPOR UE $73.93 01/01/04 01 01/01/04

E0957 W/C MEDIAL THIGH SUPPORT NU $137.93 01/01/04 01 01/01/04

E0957 W/C MEDIAL THIGH SUPPORT RR $13.79 01/01/04 01 01/01/04

E0957 W/C MEDIAL THIGH SUPPORT UE $103.45 01/01/04 01 01/01/04

E0958 WHLCHR ATT- CONV 1 ARM DRIVE RR $43.63 01/01/80 00 01/01/86

E0960 W/C SHOULDER HARNESS/STRAPS NU $90.98 01/01/04 01 01/01/04

E0960 W/C SHOULDER HARNESS/STRAPS RR $9.10 01/01/04 01 01/01/04

E0960 W/C SHOULDER HARNESS/STRAPS UE $68.24 01/01/04 01 01/01/04

E0967 MANUAL WC HAND RIM W PROJECT NU $132.13 01/01/80 00 01/01/86 2 units / 60 MO

E0967 MANUAL WC HAND RIM W PROJECT RR $13.56 01/01/80 00 01/01/86 2 units / 60 MO

E0967 MANUAL WC HAND RIM W PROJECT UE $99.13 01/01/80 00 01/01/86 2 units / 60 MO

E0968 WHEELCHAIR COMMODE SEAT RR $17.91 01/01/80 00 01/01/86

E0969 WHEELCHAIR NARROWING DEVICE NU $156.63 01/01/80 00 01/01/86 1 unit / 60 MO (RR excluded)

E0969 WHEELCHAIR NARROWING DEVICE RR $15.51 01/01/80 00 01/01/86

E0969 WHEELCHAIR NARROWING DEVICE UE $117.48 01/01/80 00 01/01/86 1 unit / 60 MO (RR excluded)

E0971 WHEELCHAIR ANTI-TIPPING DEVI NU $55.89 01/01/80 00 01/01/86 1 unit / 60 MO (RR excluded)

E0971 WHEELCHAIR ANTI-TIPPING DEVI RR $7.46 01/01/80 00 01/01/86


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E0971 WHEELCHAIR ANTI-TIPPING DEVI UE $41.91 01/01/80 00 01/01/86 1 unit / 60 MO (RR excluded)

E0973 W/CH ACCESS DET ADJ ARMREST NU $114.97 01/01/04 01 01/01/86 2 units / 60 MO

E0973 W/CH ACCESS DET ADJ ARMREST RR $10.95 01/01/04 01 01/01/86 2 units / 60 MO

E0973 W/CH ACCESS DET ADJ ARMREST UE $86.23 01/01/04 01 01/01/86 2 units / 60 MO

E0978 W/C ACC,SAF BELT PELV STRAP NU $41.36 01/01/04 00 01/01/86 1 unit / 36 MO

E0978 W/C ACC,SAF BELT PELV STRAP RR $4.28 01/01/04 00 01/01/86 1 unit / 36 MO

E0978 W/C ACC,SAF BELT PELV STRAP UE $31.02 01/01/04 00 01/01/86 1 unit / 36 MO

E0980 WHEELCHAIR SAFETY VEST NU $28.10 01/01/80 00 01/01/86 1 unit / 60 MO (RR excluded)

E0980 WHEELCHAIR SAFETY VEST RR $3.30 01/01/80 00 01/01/86

E0980 WHEELCHAIR SAFETY VEST UE $20.96 01/01/80 00 01/01/86 1 unit / 60 MO (RR excluded)

E0981 SEAT UPHOLSTERY, REPLACEMENT NU $45.51 01/01/04 01 01/01/04

E0981 SEAT UPHOLSTERY, REPLACEMENT RR $4.80 01/01/04 01 01/01/04

E0981 SEAT UPHOLSTERY, REPLACEMENT UE $34.12 01/01/04 01 01/01/04

E0982 BACK UPHOLSTERY, REPLACEMENT NU $43.80 01/01/04 01 01/01/04

E0982 BACK UPHOLSTERY, REPLACEMENT RR $5.15 01/01/04 01 01/01/04

E0982 BACK UPHOLSTERY, REPLACEMENT UE $32.84 01/01/04 01 01/01/04

E0983 ADD PWR JOYSTICK RR $238.05 01/01/04 01 01/01/04

E0984 ADD PWR TILLER NU $1,889.92 01/01/04 01 01/01/04

E0984 ADD PWR TILLER RR $177.59 01/01/04 01 01/01/04

E0984 ADD PWR TILLER UE $1,417.41 01/01/04 01 01/01/04

E0985 W/C SEAT LIFT MECHANISM NU $202.85 01/01/04 01 01/01/04

E0985 W/C SEAT LIFT MECHANISM RR $20.30 01/01/04 01 01/01/04

E0985 W/C SEAT LIFT MECHANISM UE $152.12 01/01/04 01 01/01/04

E0986 MAN W/C PUSH-RIM POW ASSIST NU $4,864.24 01/01/04 01 01/01/04

E0986 MAN W/C PUSH-RIM POW ASSIST RR $486.43 01/01/04 01 01/01/04

E0986 MAN W/C PUSH-RIM POW ASSIST UE $3,648.20 01/01/04 01 01/01/04

E0992 WHEELCHAIR SOLID SEAT INSERT NU $95.15 01/01/86 01 01/01/86 1 unit / 24 MO

E0992 WHEELCHAIR SOLID SEAT INSERT RR $9.25 01/01/86 01 01/01/86 1 unit / 24 MO

E0994 WHEELCHAIR ARM REST NU $17.63 01/01/80 00 01/01/86 2 units / 24 MO

E0994 WHEELCHAIR ARM REST RR $1.78 01/01/80 00 01/01/86 2 units / 24 MO

E0994 WHEELCHAIR ARM REST UE $13.23 01/01/80 00 01/01/86 2 units / 24 MO

E0995 WHEELCHAIR CALF REST NU $30.40 06/01/07 02 06/01/07 2 units / 24 MO

E0995 WHEELCHAIR CALF REST RR $3.05 06/01/07 02 06/01/07 2 units / 24 MO

E0995 WHEELCHAIR CALF REST UE $22.78 06/01/07 02 06/01/07 2 units / 24 MO

E1002 PWR SEAT TILT NU $4,113.02 01/01/04 01 01/01/04

E1002 PWR SEAT TILT RR $411.32 01/01/04 01 01/01/04

E1002 PWR SEAT TILT UE $3,084.76 01/01/04 01 01/01/04

E1003 PWR SEAT RECLINE NU $4,391.30 01/01/04 01 01/01/04

E1003 PWR SEAT RECLINE RR $439.14 01/01/04 01 01/01/04

E1003 PWR SEAT RECLINE UE $3,293.48 01/01/04 01 01/01/04


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E1004 PWR SEAT RECLINE MECH NU $4,869.05 01/01/04 01 01/01/04

E1004 PWR SEAT RECLINE MECH RR $486.90 01/01/04 01 01/01/04

E1004 PWR SEAT RECLINE MECH UE $3,651.77 01/01/04 01 01/01/04

E1005 PWR SEAT RECLINE PWR NU $5,270.36 01/01/04 01 01/01/04 UVSP = 2

E1005 PWR SEAT RECLINE PWR RR $527.03 01/01/04 01 01/01/04 UVSP = 2

E1005 PWR SEAT RECLINE PWR UE $3,952.78 01/01/04 01 01/01/04 UVSP = 2

E1006 PWR SEAT COMBO W/O SHEAR NU $6,455.70 01/01/04 01 01/01/04

E1006 PWR SEAT COMBO W/O SHEAR RR $645.55 01/01/04 01 01/01/04

E1006 PWR SEAT COMBO W/O SHEAR UE $4,841.78 01/01/04 01 01/01/04

E1007 PWR SEAT COMBO W/SHEAR NU $8,741.27 01/01/04 01 01/01/04

E1007 PWR SEAT COMBO W/SHEAR RR $874.13 01/01/04 01 01/01/04

E1007 PWR SEAT COMBO W/SHEAR UE $6,555.94 01/01/04 01 01/01/04

E1008 PWR SEAT COMBO PWR SHEAR NU $8,742.05 01/01/04 01 01/01/04

E1008 PWR SEAT COMBO PWR SHEAR RR $874.20 01/01/04 01 01/01/04

E1008 PWR SEAT COMBO PWR SHEAR UE $6,556.55 01/01/04 01 01/01/04

E1009 ADD MECH LEG ELEVATION NU $0.00 01/01/04 01 01/01/04

E1009 ADD MECH LEG ELEVATION RR $0.00 01/01/04 01 01/01/04

E1009 ADD MECH LEG ELEVATION UE $0.00 01/01/04 01 01/01/04

E1010 ADD PWR LEG ELEVATION NU $1,151.36 01/01/04 01 01/01/04 UVSP = 1

E1010 ADD PWR LEG ELEVATION RR $115.13 01/01/04 01 01/01/04 UVSP = 1

E1010 ADD PWR LEG ELEVATION UE $863.51 01/01/04 01 01/01/04 UVSP = 1

E1014 RECLINING BACK ADD PED W/C NU $365.14 01/01/80 01 01/01/03

E1014 RECLINING BACK ADD PED W/C RR $36.52 01/01/80 01 01/01/03

E1014 RECLINING BACK ADD PED W/C UE $273.85 01/01/80 01 01/01/03

E1015 SHOCK ABSORBER FOR MAN W/C NU $114.70 01/01/80 01 01/01/03

E1015 SHOCK ABSORBER FOR MAN W/C RR $11.46 01/01/80 01 01/01/03

E1015 SHOCK ABSORBER FOR MAN W/C UE $86.02 01/01/80 01 01/01/03

E1016 SHOCK ABSORBER FOR POWER W/C NU $131.31 01/01/80 01 01/01/03

E1016 SHOCK ABSORBER FOR POWER W/C RR $13.14 01/01/80 01 01/01/03

E1016 SHOCK ABSORBER FOR POWER W/C UE $98.48 01/01/80 01 01/01/03

E1020 RESIDUAL LIMB SUPPORT SYSTEM NU $243.41 01/01/80 01 01/01/03

E1020 RESIDUAL LIMB SUPPORT SYSTEM RR $24.32 01/01/80 01 01/01/03

E1020 RESIDUAL LIMB SUPPORT SYSTEM UE $182.55 01/01/80 01 01/01/03

E1028 W/C MANUAL SWINGAWAY NU $206.54 01/01/04 01 01/01/04

E1028 W/C MANUAL SWINGAWAY RR $20.65 01/01/04 01 01/01/04

E1028 W/C MANUAL SWINGAWAY UE $154.89 01/01/04 01 01/01/04

E1029 W/C VENT TRAY FIXED NU $369.54 01/01/04 01 01/01/04

E1029 W/C VENT TRAY FIXED RR $36.95 01/01/04 01 01/01/04

E1029 W/C VENT TRAY FIXED UE $277.15 01/01/04 01 01/01/04

E1031 ROLLABOUT CHAIR WITH CASTERS NU $505.10 01/01/80 01 01/01/90


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E1031 ROLLABOUT CHAIR WITH CASTERS RR $50.51 01/01/80 01 01/01/90

E1035 PATIENT TRANSFER SYSTEM NU $6,132.00 01/01/80 01 01/01/01

E1035 PATIENT TRANSFER SYSTEM RR $613.20 01/01/80 01 01/01/01

E1037 TRANSPORT CHAIR, PED SIZE NU $1,084.90 01/01/80 01 01/01/03

E1037 TRANSPORT CHAIR, PED SIZE RR $108.49 01/01/80 01 01/01/03

E1038 TRANSPORT CHAIR PT WT<=300LB NU $400.10 01/01/80 01 01/01/03

E1038 TRANSPORT CHAIR PT WT<=300LB RR $40.01 01/01/80 01 01/01/03

E1039 TRANSPORT CHAIR PT WT >300LB RR $22.65 01/01/05 01 01/01/05

E1050 WHELCHR FXD FULL LENGTH ARMS RR $101.84 01/01/80 01 11/01/02 93 days / cal YR

E1060 WHEELCHAIR DETACHABLE ARMS RR $126.07 01/01/80 01 11/01/02 93 days / cal YR

E1070 WHEELCHAIR DETACHABLE FOOT R RR $93.33 01/01/80 01 11/01/02 93 days / cal YR

E1083 HEMI-WHEELCHAIR FIXED ARMS RR $73.12 01/01/80 01 11/01/02 93 days / cal YR

E1084 HEMI-WHEELCHAIR DETACHABLE A RR $98.10 01/01/80 01 11/01/02 93 days / cal YR

E1087 WHEELCHAIR LIGHTWT FIXED ARM RR $107.53 01/01/80 01 11/01/02 93 days / cal YR

E1088 WHEELCHAIR LIGHTWEIGHT DET A RR $150.77 01/01/80 01 11/01/02 93 days / cal YR

E1092 WHEELCHAIR WIDE W/ LEG RESTS RR $128.51 01/01/80 01 11/01/02 93 days / cal YR

E1093 WHEELCHAIR WIDE W/ FOOT REST RR $110.52 01/01/80 01 11/01/02 93 days / cal YR

E1100 WHCHR S-RECL FXD ARM LEG RES RR $97.82 01/01/80 01 11/01/02

E1110 WHEELCHAIR SEMI-RECL DETACH RR $97.82 01/01/80 01 11/01/02

E1150 WHEELCHAIR STANDARD W/ LEG R RR $81.58 01/01/80 01 11/01/02 93 days / cal YR

E1160 WHEELCHAIR FIXED ARMS RR $62.50 01/01/80 01 11/01/02 93 days / cal YR

E1161 MANUAL ADULT WC W TILTINSPAC NU $2,366.09 01/01/03 01 01/01/03

E1161 MANUAL ADULT WC W TILTINSPAC RR $235.92 01/01/80 01 01/01/03

E1170 WHLCHR AMPU FXD ARM LEG REST RR $89.31 01/01/80 01 11/01/02 93 days / cal YR

E1171 WHEELCHAIR AMPUTEE W/O LEG R RR $80.15 01/01/80 01 11/01/02 93 days / cal YR

E1172 WHEELCHAIR AMPUTEE DETACH AR RR $95.67 01/01/80 01 11/01/02 93 days / cal YR

E1180 WHEELCHAIR AMPUTEE W/ FOOT R RR $101.34 01/01/80 01 11/01/02 93 days / cal YR

E1190 WHEELCHAIR AMPUTEE W/ LEG RE RR $99.51 01/01/80 01 11/01/02 93 days / cal YR

E1195 WHEELCHAIR AMPUTEE HEAVY DUT RR $125.63 01/01/80 01 11/01/02 93 days / cal YR

E1200 WHEELCHAIR AMPUTEE FIXED ARM RR $87.01 01/01/80 01 11/01/02 93 days / cal YR

E1221 WHEELCHAIR SPEC SIZE W FOOT RR $47.51 01/01/80 00 01/01/86

E1222 WHEELCHAIR SPEC SIZE W/ LEG RR $67.79 01/01/80 00 01/01/86

E1223 WHEELCHAIR SPEC SIZE W FOOT RR $74.02 01/01/80 00 01/01/86

E1224 WHEELCHAIR SPEC SIZE W/ LEG RR $81.15 01/01/80 00 01/01/86

E1225 MANUAL SEMI-RECLINING BACK RR $45.20 01/01/80 00 01/01/86

E1226 MANUAL FULLY RECLINING BACK NU $490.25 09/01/03 01 09/01/03

E1226 MANUAL FULLY RECLINING BACK RR $49.04 09/01/03 01 09/01/03

E1226 MANUAL FULLY RECLINING BACK UE $367.69 09/01/03 01 09/01/03

E1227 WHEELCHAIR SPEC SZ SPEC HT A NU $235.88 01/01/80 01 11/01/02

E1227 WHEELCHAIR SPEC SZ SPEC HT A RR $23.59 01/01/80 01 11/01/02


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E1227 WHEELCHAIR SPEC SZ SPEC HT A UE $176.93 01/01/80 01 11/01/02

E1228 WHEELCHAIR SPEC SZ SPEC HT B RR $28.02 01/01/80 01 11/01/02

E1229 PEDIATRIC WHEELCHAIR NOS $0.00 01/01/05 01 01/01/05

E1230 POWER OPERATED VEHICLE NU $2,261.79 01/01/80 01 01/01/86

E1230 POWER OPERATED VEHICLE RR $222.45 01/01/80 01 01/01/86

E1230 POWER OPERATED VEHICLE UE $1,788.81 01/01/80 01 01/01/86

E1232 FOLDING PED WC TILT-IN-SPACE NU $2,134.20 01/01/80 01 01/01/03

E1232 FOLDING PED WC TILT-IN-SPACE RR $213.42 01/01/80 01 01/01/03

E1233 RIG PED WC TLTNSPC W/O SEAT NU $2,208.50 01/01/80 01 01/01/03

E1233 RIG PED WC TLTNSPC W/O SEAT RR $220.85 01/01/80 01 01/01/03

E1234 FLD PED WC TLTNSPC W/O SEAT NU $1,923.20 01/01/80 01 01/01/03

E1234 FLD PED WC TLTNSPC W/O SEAT RR $192.32 01/01/80 01 01/01/03

E1235 RIGID PED WC ADJUSTABLE NU $1,851.90 01/01/80 01 01/01/03

E1235 RIGID PED WC ADJUSTABLE RR $185.19 01/01/80 01 01/01/03

E1236 FOLDING PED WC ADJUSTABLE NU $1,633.40 01/01/80 01 01/01/03

E1236 FOLDING PED WC ADJUSTABLE RR $163.34 01/01/80 01 01/01/03

E1237 RGD PED WC ADJSTABL W/O SEAT NU $1,648.10 01/01/80 01 01/01/03

E1237 RGD PED WC ADJSTABL W/O SEAT RR $164.81 01/01/80 01 01/01/03

E1238 FLD PED WC ADJSTABL W/O SEAT NU $1,718.60 01/01/80 01 01/01/03

E1238 FLD PED WC ADJSTABL W/O SEAT RR $171.86 01/01/80 01 01/01/03

E1239 PED POWER WHEELCHAIR NOS $0.00 01/01/05 01 01/01/05

E1240 WHCHR LITWT DET ARM LEG REST RR $92.03 01/01/80 00 01/01/86

E1270 WHEELCHAIR LIGHTWEIGHT LEG R RR $76.09 01/01/80 00 01/01/86

E1280 WHCHR H-DUTY DET ARM LEG RES RR $131.26 01/01/80 00 01/01/86 93 days / cal YR

E1295 WHEELCHAIR HEAVY DUTY FIXED RR $121.47 01/01/80 01 11/01/02 93 days / cal YR

E1296 WHEELCHAIR SPECIAL SEAT HEIG NU $417.92 01/01/80 01 11/01/02 1 unit / 60 MO (RR excluded)

E1296 WHEELCHAIR SPECIAL SEAT HEIG RR $42.45 01/01/80 01 11/01/02

E1296 WHEELCHAIR SPECIAL SEAT HEIG UE $313.44 01/01/80 01 11/01/02 1 unit / 60 MO (RR excluded)

E1297 WHEELCHAIR SPECIAL SEAT DEPT NU $104.61 01/01/80 01 11/01/02 1 unit / 60 MO (RR excluded)

E1297 WHEELCHAIR SPECIAL SEAT DEPT RR $11.62 01/01/80 01 11/01/02

E1297 WHEELCHAIR SPECIAL SEAT DEPT UE $78.45 01/01/80 01 11/01/02 1 unit / 60 MO (RR excluded)

E1298 WHEELCHAIR SPEC SEAT DEPTH/W NU $423.65 01/01/80 01 11/01/02 1 unit / 60 MO (RR excluded)

E1298 WHEELCHAIR SPEC SEAT DEPTH/W RR $43.35 01/01/80 01 11/01/02

E1298 WHEELCHAIR SPEC SEAT DEPTH/W UE $317.73 01/01/80 01 11/01/02 1 unit / 60 MO (RR excluded)

E1372 OXY SUPPL HEATER FOR NEBULIZ NU $138.58 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E1372 OXY SUPPL HEATER FOR NEBULIZ RR $20.14 01/01/80 01 01/01/86

E1372 OXY SUPPL HEATER FOR NEBULIZ UE $102.58 01/01/80 01 01/01/86 1 unit / 60 MO (RR excluded)

E1390 OXYGEN CONCENTRATOR RR $228.80 01/01/80 01 01/01/00

E1391 OXYGEN CONCENTRATOR, DUAL RR $228.80 01/01/04 01 01/01/04 UVSP = 31

E1392 PORTABLE OXYGEN CONCENTRATOR RR $32.07 01/01/06 01 01/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E1399 DURABLE MEDICAL EQUIPMENT MI $0.00 01/01/80 01 01/01/86

E1405 O2/WATER VAPOR ENRICH W/HEAT RR $258.61 01/01/80 01 01/01/88 186 units / 6 MO

E1406 O2/WATER VAPOR ENRICH W/O HE RR $245.57 01/01/80 01 01/01/88

E1702 REPL MEASR SCALES JAW MOTION $22.57 01/01/80 01 11/01/02

E1800 ADJUST ELBOW EXT/FLEX DEVICE RR $122.50 01/01/80 01 11/01/02

E1801 SPS ELBOW DEVICE RR $122.63 01/01/80 01 11/01/02

E1802 ADJST FOREARM PRO/SUP DEVICE RR $326.80 01/01/80 01 11/01/02

E1805 ADJUST WRIST EXT/FLEX DEVICE RR $126.34 01/01/80 01 11/01/02

E1806 SPS WRIST DEVICE RR $100.67 01/01/80 01 11/01/02

E1810 ADJUST KNEE EXT/FLEX DEVICE RR $124.58 01/01/80 01 01/01/96

E1811 SPS KNEE DEVICE RR $127.49 01/01/80 01 11/01/02

E1812 KNEE EXT/FLEX W ACT RES CTRL RR $85.99 07/01/06 01 01/01/06

E1815 ADJUST ANKLE EXT/FLEX DEVICE RR $126.34 01/01/80 01 11/01/02

E1816 SPS ANKLE DEVICE RR $129.49 01/01/80 01 11/01/02

E1818 SPS FOREARM DEVICE RR $132.17 01/01/80 01 11/01/02

E1820 SOFT INTERFACE MATERIAL NU $77.11 01/01/80 01 11/01/02

E1820 SOFT INTERFACE MATERIAL RR $7.72 01/01/80 01 11/01/02

E1820 SOFT INTERFACE MATERIAL UE $57.83 01/01/80 01 11/01/02

E1821 REPLACEMENT INTERFACE SPSD NU $105.25 01/01/80 01 11/01/02

E1821 REPLACEMENT INTERFACE SPSD RR $10.51 01/01/80 01 11/01/02

E1821 REPLACEMENT INTERFACE SPSD UE $78.95 01/01/80 01 11/01/02

E1825 ADJUST FINGER EXT/FLEX DEVC RR $126.34 01/01/80 01 11/01/02

E1830 ADJUST TOE EXT/FLEX DEVICE RR $126.34 01/01/80 01 11/01/02

E1840 ADJ SHOULDER EXT/FLEX DEVICE RR $375.18 01/01/80 01 11/01/02

E1902 AAC NON-ELECTRONIC BOARD $0.00 08/01/08 01 08/01/08 1 unit / 60 MO

E2000 GASTRIC SUCTION PUMP HME MDL NU $492.50 01/01/80 01 01/01/02

E2000 GASTRIC SUCTION PUMP HME MDL RR $49.25 01/01/80 01 01/01/02

E2201 MAN W/CH ACC SEAT W>=20�<24� NU $373.10 01/01/04 01 01/01/04

E2201 MAN W/CH ACC SEAT W>=20�<24� RR $37.31 01/01/04 01 01/01/04

E2201 MAN W/CH ACC SEAT W>=20�<24� UE $279.83 01/01/04 01 01/01/04

E2202 SEAT WIDTH 24-27 IN NU $473.98 01/01/04 01 01/01/04

E2202 SEAT WIDTH 24-27 IN RR $47.40 01/01/04 01 01/01/04

E2202 SEAT WIDTH 24-27 IN UE $355.50 01/01/04 01 01/01/04

E2203 FRAME DEPTH LESS THAN 22 IN NU $479.05 01/01/04 01 01/01/04

E2203 FRAME DEPTH LESS THAN 22 IN RR $47.89 01/01/04 01 01/01/04

E2203 FRAME DEPTH LESS THAN 22 IN UE $359.28 01/01/04 01 01/01/04

E2204 FRAME DEPTH 22 TO 25 IN NU $813.40 01/01/04 01 01/01/04

E2204 FRAME DEPTH 22 TO 25 IN RR $81.35 01/01/04 01 01/01/04

E2204 FRAME DEPTH 22 TO 25 IN UE $610.05 01/01/04 01 01/01/04

E2205 MANUAL WC ACCESSORY, HANDRIM NU $32.10 01/01/05 01 01/01/05


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2205 MANUAL WC ACCESSORY, HANDRIM RR $3.19 01/01/05 01 01/01/05

E2205 MANUAL WC ACCESSORY, HANDRIM UE $24.10 01/01/05 01 01/01/05

E2206 COMPLETE WHEEL LOCK ASSEMBLY NU $40.01 01/01/05 01 01/01/05

E2206 COMPLETE WHEEL LOCK ASSEMBLY RR $3.99 01/01/05 01 01/01/05

E2206 COMPLETE WHEEL LOCK ASSEMBLY UE $30.01 01/01/05 01 01/01/05

E2207 CRUTCH AND CANE HOLDER NU $42.62 01/01/06 01 01/01/06

E2207 CRUTCH AND CANE HOLDER RR $4.27 01/01/06 01 01/01/06

E2207 CRUTCH AND CANE HOLDER UE $31.97 01/01/06 01 01/01/06

E2208 CYLINDER TANK CARRIER NU $116.20 01/01/06 01 01/01/06

E2208 CYLINDER TANK CARRIER RR $11.68 01/01/06 01 01/01/06

E2208 CYLINDER TANK CARRIER UE $87.59 01/01/06 01 01/01/06

E2209 ARM TROUGH EACH NU $105.39 01/01/06 01 01/01/06

E2209 ARM TROUGH EACH RR $10.52 01/01/06 01 01/01/06

E2209 ARM TROUGH EACH UE $79.04 01/01/06 01 01/01/06

E2210 WHEELCHAIR BEARINGS NU $6.55 01/01/06 00 01/01/06

E2210 WHEELCHAIR BEARINGS RR $0.66 01/01/06 00 01/01/06

E2210 WHEELCHAIR BEARINGS UE $4.92 01/01/06 00 01/01/06

E2211 PNEUMATIC PROPULSION TIRE NU $34.77 01/01/06 00 01/01/06

E2211 PNEUMATIC PROPULSION TIRE RR $4.01 01/01/06 00 01/01/06

E2211 PNEUMATIC PROPULSION TIRE UE $24.91 01/01/06 00 01/01/06

E2212 PNEUMATIC PROP TIRE TUBE NU $5.78 01/01/06 00 01/01/06

E2212 PNEUMATIC PROP TIRE TUBE RR $0.61 01/01/06 00 01/01/06

E2212 PNEUMATIC PROP TIRE TUBE UE $4.34 01/01/06 00 01/01/06

E2213 PNEUMATIC PROP TIRE INSERT NU $29.91 01/01/06 00 01/01/06

E2213 PNEUMATIC PROP TIRE INSERT RR $3.01 01/01/06 00 01/01/06

E2213 PNEUMATIC PROP TIRE INSERT UE $22.41 01/01/06 00 01/01/06

E2214 PNEUMATIC CASTER TIRE EACH NU $30.82 01/01/06 00 01/01/06

E2214 PNEUMATIC CASTER TIRE EACH RR $3.96 01/01/06 00 01/01/06

E2214 PNEUMATIC CASTER TIRE EACH UE $23.10 01/01/06 00 01/01/06

E2215 PNEUMATIC CASTER TIRE TUBE NU $9.45 01/01/06 00 01/01/06

E2215 PNEUMATIC CASTER TIRE TUBE RR $0.94 01/01/06 00 01/01/06

E2215 PNEUMATIC CASTER TIRE TUBE UE $7.08 01/01/06 00 01/01/06

E2216 FOAM FILLED PROPULSION TIRE NU $28.42 09/01/08 00 01/01/06

E2216 FOAM FILLED PROPULSION TIRE RR $2.84 09/01/08 00 01/01/06

E2216 FOAM FILLED PROPULSION TIRE UE $21.32 09/01/08 00 01/01/06

E2217 FOAM FILLED CASTER TIRE EACH NU $0.00 01/01/06 00 01/01/06

E2217 FOAM FILLED CASTER TIRE EACH RR $0.00 01/01/06 00 01/01/06

E2217 FOAM FILLED CASTER TIRE EACH UE $0.00 01/01/06 00 01/01/06

E2218 FOAM PROPULSION TIRE EACH NU $16.74 09/01/08 00 01/01/06

E2218 FOAM PROPULSION TIRE EACH RR $1.67 09/01/08 00 01/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2218 FOAM PROPULSION TIRE EACH UE $12.56 09/01/08 00 01/01/06

E2219 FOAM CASTER TIRE ANY SIZE EA NU $35.57 01/01/06 00 01/01/06

E2219 FOAM CASTER TIRE ANY SIZE EA RR $4.72 01/01/06 00 01/01/06

E2219 FOAM CASTER TIRE ANY SIZE EA UE $26.68 01/01/06 00 01/01/06

E2220 SOLID PROPULSION TIRE EACH NU $28.52 01/01/06 00 01/01/06

E2220 SOLID PROPULSION TIRE EACH RR $2.75 01/01/06 00 01/01/06

E2220 SOLID PROPULSION TIRE EACH UE $21.81 01/01/06 00 01/01/06

E2221 SOLID CASTER TIRE EACH NU $25.12 01/01/06 00 01/01/06

E2221 SOLID CASTER TIRE EACH RR $2.49 01/01/06 00 01/01/06

E2221 SOLID CASTER TIRE EACH UE $18.86 01/01/06 00 01/01/06

E2222 SOLID CASTER INTEGRATED WHL NU $21.03 07/01/06 00 01/01/06

E2222 SOLID CASTER INTEGRATED WHL RR $2.09 07/01/06 00 01/01/06

E2222 SOLID CASTER INTEGRATED WHL UE $15.81 07/01/06 00 01/01/06

E2223 VALVE REPLACEMENT ONLY EACH NU $5.61 07/01/06 00 01/01/06

E2223 VALVE REPLACEMENT ONLY EACH RR $0.56 07/01/06 00 01/01/06

E2223 VALVE REPLACEMENT ONLY EACH UE $4.21 07/01/06 00 01/01/06

E2224 PROPULSION WHL EXCLUDES TIRE NU $83.85 01/01/06 00 01/01/06

E2224 PROPULSION WHL EXCLUDES TIRE RR $10.29 01/01/06 00 01/01/06

E2224 PROPULSION WHL EXCLUDES TIRE UE $62.52 01/01/06 00 01/01/06

E2225 CASTER WHEEL EXCLUDES TIRE NU $17.40 07/01/06 00 01/01/06

E2225 CASTER WHEEL EXCLUDES TIRE RR $1.71 07/01/06 00 01/01/06

E2225 CASTER WHEEL EXCLUDES TIRE UE $13.04 07/01/06 00 01/01/06

E2226 CASTER FORK REPLACEMENT ONLY NU $37.94 07/01/06 00 01/01/06

E2226 CASTER FORK REPLACEMENT ONLY RR $3.79 07/01/06 00 01/01/06

E2226 CASTER FORK REPLACEMENT ONLY UE $28.46 07/01/06 00 01/01/06

E2227 Gear reduction drive wheel NU $0.00 01/01/08 01 01/01/08

E2227 Gear reduction drive wheel RR $0.00 01/01/08 01 01/01/08

E2227 Gear reduction drive wheel UE $0.00 01/01/08 01 01/01/08

E2228 Mwc acc wheelchair brake NU $0.00 01/01/08 01 01/01/08

E2228 Mwc acc wheelchair brake RR $0.00 01/01/08 01 01/01/08

E2228 Mwc acc wheelchair brake UE $0.00 01/01/08 01 01/01/08

E2231 SOLID SEAT SUPPORT BASE NU $161.36 01/01/09 00 01/01/09

E2231 SOLID SEAT SUPPORT BASE RR $16.14 01/01/09 00 01/01/09

E2231 SOLID SEAT SUPPORT BASE UE $121.01 01/01/09 00 01/01/09

E2291 PLANAR BACK FOR PED SIZE WC NU $170.55 09/01/08 01 01/01/05

E2291 PLANAR BACK FOR PED SIZE WC RR $17.06 09/01/08 01 01/01/05

E2291 PLANAR BACK FOR PED SIZE WC UE $127.91 09/01/08 01 01/01/05

E2292 PLANAR SEAT FOR PED SIZE WC NU $170.55 09/01/08 01 01/01/05

E2292 PLANAR SEAT FOR PED SIZE WC RR $17.06 09/01/08 01 01/01/05

E2292 PLANAR SEAT FOR PED SIZE WC UE $127.91 09/01/08 01 01/01/05


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2293 CONTOUR BACK FOR PED SIZE WC NU $227.40 09/01/08 01 01/01/05

E2293 CONTOUR BACK FOR PED SIZE WC RR $22.74 09/01/08 01 01/01/05

E2293 CONTOUR BACK FOR PED SIZE WC UE $170.55 09/01/08 01 01/01/05

E2294 CONTOUR SEAT FOR PED SIZE WC NU $227.40 09/01/08 01 01/01/05

E2294 CONTOUR SEAT FOR PED SIZE WC RR $22.74 09/01/08 01 01/01/05

E2294 CONTOUR SEAT FOR PED SIZE WC UE $170.55 09/01/08 01 01/01/05

E2295 PED DYNAMIC SEATING FRAME $0.00 01/01/09 01 01/01/09 UVSP = 1

E2310 ELECTRO CONNECT BTW CONTROL NU $1,170.24 01/01/04 01 01/01/04

E2310 ELECTRO CONNECT BTW CONTROL RR $117.02 01/01/04 01 01/01/04

E2310 ELECTRO CONNECT BTW CONTROL UE $877.68 01/01/04 01 01/01/04

E2311 ELECTRO CONNECT BTW 2 SYS NU $2,369.20 01/01/04 01 01/01/04

E2311 ELECTRO CONNECT BTW 2 SYS RR $236.93 01/01/04 01 01/01/04

E2311 ELECTRO CONNECT BTW 2 SYS UE $1,776.90 01/01/04 01 01/01/04

E2312 Mini-prop remote joystick NU $1,939.18 01/01/08 01 01/01/08

E2312 Mini-prop remote joystick RR $193.92 01/01/08 01 01/01/08

E2312 Mini-prop remote joystick UE $1,454.36 01/01/08 01 01/01/08

E2313 PWC harness expand control NU $307.93 01/01/08 01 01/01/08

E2313 PWC harness expand control RR $30.81 01/01/08 01 01/01/08

E2313 PWC harness expand control UE $230.95 01/01/08 01 01/01/08

E2321 HAND INTERFACE JOYSTICK NU $1,532.90 01/01/04 01 01/01/04

E2321 HAND INTERFACE JOYSTICK RR $153.28 01/01/04 01 01/01/04

E2321 HAND INTERFACE JOYSTICK UE $1,149.68 01/01/04 01 01/01/04

E2322 MULT MECH SWITCHES NU $1,410.36 01/01/04 01 01/01/04

E2322 MULT MECH SWITCHES RR $141.03 01/01/04 01 01/01/04

E2322 MULT MECH SWITCHES UE $1,057.78 01/01/04 01 01/01/04

E2323 SPECIAL JOYSTICK HANDLE NU $64.64 01/01/04 01 01/01/04

E2323 SPECIAL JOYSTICK HANDLE RR $6.47 01/01/04 01 01/01/04

E2323 SPECIAL JOYSTICK HANDLE UE $48.48 01/01/04 01 01/01/04

E2324 CHIN CUP INTERFACE NU $44.49 01/01/04 01 01/01/04

E2324 CHIN CUP INTERFACE RR $4.45 01/01/04 01 01/01/04

E2324 CHIN CUP INTERFACE UE $33.37 01/01/04 01 01/01/04

E2325 SIP AND PUFF INTERFACE NU $1,346.83 01/01/04 01 01/01/04

E2325 SIP AND PUFF INTERFACE RR $134.70 01/01/04 01 01/01/04

E2325 SIP AND PUFF INTERFACE UE $1,010.13 01/01/04 01 01/01/04

E2326 BREATH TUBE KIT NU $319.60 01/01/04 01 01/01/04

E2326 BREATH TUBE KIT RR $31.96 01/01/04 01 01/01/04

E2326 BREATH TUBE KIT UE $239.72 01/01/04 01 01/01/04

E2327 HEAD CONTROL INTERFACE MECH NU $2,306.14 01/01/04 01 01/01/04

E2327 HEAD CONTROL INTERFACE MECH RR $230.62 01/01/04 01 01/01/04

E2327 HEAD CONTROL INTERFACE MECH UE $1,729.58 01/01/04 01 01/01/04


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2328 HEAD/EXTREMITY CONTROL INTER NU $3,877.22 01/01/04 01 01/01/04

E2328 HEAD/EXTREMITY CONTROL INTER RR $387.44 01/01/04 01 01/01/04

E2328 HEAD/EXTREMITY CONTROL INTER UE $2,908.01 01/01/04 01 01/01/04

E2329 HEAD CONTROL NONPROPORTIONAL NU $1,730.21 01/01/04 01 01/01/04

E2329 HEAD CONTROL NONPROPORTIONAL RR $173.04 01/01/04 01 01/01/04

E2329 HEAD CONTROL NONPROPORTIONAL UE $1,297.72 01/01/04 01 01/01/04

E2330 HEAD CONTROL PROXIMITY SWITC NU $3,333.27 01/01/04 01 01/01/04

E2330 HEAD CONTROL PROXIMITY SWITC RR $333.32 01/01/04 01 01/01/04

E2330 HEAD CONTROL PROXIMITY SWITC UE $2,499.96 01/01/04 01 01/01/04

E2340 W/C WDTH 20-23 IN SEAT FRAME NU $314.22 01/01/04 01 01/01/04

E2340 W/C WDTH 20-23 IN SEAT FRAME RR $31.42 01/01/04 01 01/01/04

E2340 W/C WDTH 20-23 IN SEAT FRAME UE $235.67 01/01/04 01 01/01/04

E2341 W/C WDTH 24-27 IN SEAT FRAME NU $462.97 01/01/04 01 01/01/04

E2341 W/C WDTH 24-27 IN SEAT FRAME RR $46.30 01/01/04 01 01/01/04

E2341 W/C WDTH 24-27 IN SEAT FRAME UE $347.23 01/01/04 01 01/01/04

E2342 W/C DPTH 20-21 IN SEAT FRAME NU $448.03 01/01/04 01 01/01/04

E2342 W/C DPTH 20-21 IN SEAT FRAME RR $44.80 01/01/04 01 01/01/04

E2342 W/C DPTH 20-21 IN SEAT FRAME UE $336.03 01/01/04 01 01/01/04

E2343 W/C DPTH 22-25 IN SEAT FRAME NU $259.27 01/01/04 01 01/01/04

E2343 W/C DPTH 22-25 IN SEAT FRAME RR $25.93 01/01/04 01 01/01/04

E2343 W/C DPTH 22-25 IN SEAT FRAME UE $194.44 01/01/04 01 01/01/04

E2351 ELECTRONIC SGD INTERFACE NU $698.63 01/01/04 01 01/01/04

E2351 ELECTRONIC SGD INTERFACE RR $69.88 01/01/04 01 01/01/04

E2351 ELECTRONIC SGD INTERFACE UE $523.96 01/01/04 01 01/01/04

E2360 22NF NONSEALED LEADACID NU $112.34 01/01/04 01 01/01/04

E2360 22NF NONSEALED LEADACID RR $11.29 01/01/04 01 01/01/04

E2360 22NF NONSEALED LEADACID UE $84.26 01/01/04 01 01/01/04

E2361 22NF SEALED LEADACID BATTERY NU $137.15 01/01/04 00 01/01/04

E2361 22NF SEALED LEADACID BATTERY RR $13.72 01/01/04 00 01/01/04

E2361 22NF SEALED LEADACID BATTERY UE $102.86 01/01/04 00 01/01/04

E2362 GR24 NONSEALED LEADACID NU $90.44 01/01/04 01 01/01/04

E2362 GR24 NONSEALED LEADACID RR $9.04 01/01/04 01 01/01/04

E2362 GR24 NONSEALED LEADACID UE $67.82 01/01/04 01 01/01/04

E2363 GR24 SEALED LEADACID BATTERY NU $182.89 01/01/04 00 01/01/04

E2363 GR24 SEALED LEADACID BATTERY RR $18.30 01/01/04 00 01/01/04

E2363 GR24 SEALED LEADACID BATTERY UE $137.17 01/01/04 00 01/01/04

E2364 U1NONSEALED LEADACID BATTERY NU $112.34 01/01/04 01 01/01/04

E2364 U1NONSEALED LEADACID BATTERY RR $11.29 01/01/04 01 01/01/04

E2364 U1NONSEALED LEADACID BATTERY UE $84.26 01/01/04 01 01/01/04

E2365 U1 SEALED LEADACID BATTERY NU $110.31 01/01/04 00 01/01/04


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2365 U1 SEALED LEADACID BATTERY RR $11.03 01/01/04 00 01/01/04

E2365 U1 SEALED LEADACID BATTERY UE $82.75 01/01/04 00 01/01/04

E2366 BATTERY CHARGER, SINGLE MODE NU $224.08 01/01/04 00 01/01/04

E2366 BATTERY CHARGER, SINGLE MODE RR $22.47 01/01/04 00 01/01/04

E2366 BATTERY CHARGER, SINGLE MODE UE $168.06 01/01/04 00 01/01/04

E2367 BATTERY CHARGER, DUAL MODE NU $419.08 01/01/04 01 01/01/04

E2367 BATTERY CHARGER, DUAL MODE RR $41.91 01/01/04 01 01/01/04

E2367 BATTERY CHARGER, DUAL MODE UE $314.31 01/01/04 01 01/01/04

E2368 POWER WC MOTOR REPLACEMENT NU $516.57 01/01/05 01 01/01/05

E2368 POWER WC MOTOR REPLACEMENT RR $51.67 01/01/05 01 01/01/05

E2368 POWER WC MOTOR REPLACEMENT UE $387.44 01/01/05 01 01/01/05

E2369 PWR WC GEAR BOX REPLACEMENT NU $449.94 01/01/05 01 01/01/05

E2369 PWR WC GEAR BOX REPLACEMENT RR $45.00 01/01/05 01 01/01/05

E2369 PWR WC GEAR BOX REPLACEMENT UE $337.45 01/01/05 01 01/01/05

E2370 PWR WC MOTOR/GEAR BOX COMBO NU $802.84 01/01/05 01 01/01/05

E2370 PWR WC MOTOR/GEAR BOX COMBO RR $80.29 01/01/05 01 01/01/05

E2370 PWR WC MOTOR/GEAR BOX COMBO UE $602.12 01/01/05 01 01/01/05

E2371 GR27 SEALED LEADACID BATTERY NU $150.74 07/01/06 00 01/01/06

E2371 GR27 SEALED LEADACID BATTERY RR $15.08 07/01/06 00 01/01/06

E2371 GR27 SEALED LEADACID BATTERY UE $113.06 07/01/06 00 01/01/06

E2372 GR27 NON-SEALED LEADACID NU $0.00 01/01/06 00 01/01/06

E2372 GR27 NON-SEALED LEADACID RR $0.00 01/01/06 00 01/01/06

E2372 GR27 NON-SEALED LEADACID UE $0.00 01/01/06 00 01/01/06

E2373 HAND/CHIN CTRL SPEC JOYSTICK NU $675.92 08/01/08 01 01/01/07

E2373 HAND/CHIN CTRL SPEC JOYSTICK RR $67.61 08/01/08 01 01/01/07

E2373 HAND/CHIN CTRL SPEC JOYSTICK UE $506.96 08/01/08 01 01/01/07

E2374 HAND/CHIN CTRL STD JOYSTICK NU $534.02 08/01/08 01 01/01/07

E2374 HAND/CHIN CTRL STD JOYSTICK RR $53.40 08/01/08 01 01/01/07

E2374 HAND/CHIN CTRL STD JOYSTICK UE $400.53 08/01/08 01 01/01/07

E2375 NON-EXPANDABLE CONTROLLER NU $856.56 08/01/08 01 01/01/07

E2375 NON-EXPANDABLE CONTROLLER RR $85.65 08/01/08 01 01/01/07

E2375 NON-EXPANDABLE CONTROLLER UE $642.40 08/01/08 01 01/01/07

E2376 EXPANDABLE CONTROLLER REPL NU $1,342.27 08/01/08 01 01/01/07

E2376 EXPANDABLE CONTROLLER REPL RR $134.23 08/01/08 01 01/01/07

E2376 EXPANDABLE CONTROLLER REPL UE $1,006.72 08/01/08 01 01/01/07

E2377 EXPANDABLE CONTROLLER INITL NU $485.71 08/01/08 01 01/01/07

E2377 EXPANDABLE CONTROLLER INITL RR $48.56 08/01/08 01 01/01/07

E2377 EXPANDABLE CONTROLLER INITL UE $364.30 08/01/08 01 01/01/07

E2381 PNEUM DRIVE WHEEL TIRE NU $74.90 01/01/07 00 01/01/07

E2381 PNEUM DRIVE WHEEL TIRE RR $7.47 01/01/07 00 01/01/07


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2381 PNEUM DRIVE WHEEL TIRE UE $56.18 01/01/07 00 01/01/07

E2382 TUBE PNEUM WHEEL DRIVE TIRE NU $20.41 01/01/07 00 01/01/07

E2382 TUBE PNEUM WHEEL DRIVE TIRE RR $2.02 01/01/07 00 01/01/07

E2382 TUBE PNEUM WHEEL DRIVE TIRE UE $15.32 01/01/07 00 01/01/07

E2383 INSERT PNEUM WHEEL DRIVE NU $149.34 01/01/07 00 01/01/07

E2383 INSERT PNEUM WHEEL DRIVE RR $14.93 01/01/07 00 01/01/07

E2383 INSERT PNEUM WHEEL DRIVE UE $112.02 01/01/07 00 01/01/07

E2384 PNEUMATIC CASTER TIRE NU $79.57 01/01/07 00 01/01/07

E2384 PNEUMATIC CASTER TIRE RR $7.94 01/01/07 00 01/01/07

E2384 PNEUMATIC CASTER TIRE UE $59.67 01/01/07 00 01/01/07

E2385 TUBE PNEUMATIC CASTER TIRE NU $48.67 01/01/07 00 01/01/07

E2385 TUBE PNEUMATIC CASTER TIRE RR $4.85 01/01/07 00 01/01/07

E2385 TUBE PNEUMATIC CASTER TIRE UE $36.50 01/01/07 00 01/01/07

E2386 FOAM FILLED DRIVE WHEEL TIRE NU $147.98 01/01/07 00 01/01/07

E2386 FOAM FILLED DRIVE WHEEL TIRE RR $14.80 01/01/07 00 01/01/07

E2386 FOAM FILLED DRIVE WHEEL TIRE UE $111.01 01/01/07 00 01/01/07

E2387 FOAM FILLED CASTER TIRE NU $63.84 01/01/07 00 01/01/07

E2387 FOAM FILLED CASTER TIRE RR $6.37 01/01/07 00 01/01/07

E2387 FOAM FILLED CASTER TIRE UE $47.87 01/01/07 00 01/01/07

E2388 FOAM DRIVE WHEEL TIRE NU $50.39 08/01/08 00 01/01/07

E2388 FOAM DRIVE WHEEL TIRE RR $5.04 08/01/08 00 01/01/07

E2388 FOAM DRIVE WHEEL TIRE UE $37.80 08/01/08 00 01/01/07

E2389 FOAM CASTER TIRE NU $27.36 08/01/08 00 01/01/07

E2389 FOAM CASTER TIRE RR $2.74 08/01/08 00 01/01/07

E2389 FOAM CASTER TIRE UE $20.51 08/01/08 00 01/01/07

E2390 SOLID DRIVE WHEEL TIRE NU $42.79 08/01/08 00 01/01/07

E2390 SOLID DRIVE WHEEL TIRE RR $4.28 08/01/08 00 01/01/07

E2390 SOLID DRIVE WHEEL TIRE UE $32.07 08/01/08 00 01/01/07

E2391 SOLID CASTER TIRE NU $20.50 08/01/08 00 01/01/07

E2391 SOLID CASTER TIRE RR $2.05 08/01/08 00 01/01/07

E2391 SOLID CASTER TIRE UE $15.38 08/01/08 00 01/01/07

E2392 SOLID CASTER TIRE INTEGRATE NU $53.88 08/01/08 00 01/01/07

E2392 SOLID CASTER TIRE INTEGRATE RR $5.40 08/01/08 00 01/01/07

E2392 SOLID CASTER TIRE INTEGRATE UE $40.41 08/01/08 00 01/01/07

E2393 VALVE PNEUMATIC TIRE TUBE NU $0.00 01/01/07 00 01/01/07

E2393 VALVE PNEUMATIC TIRE TUBE RR $0.00 01/01/07 00 01/01/07

E2393 VALVE PNEUMATIC TIRE TUBE UE $0.00 01/01/07 00 01/01/07

E2394 DRIVE WHEEL EXCLUDES TIRE NU $76.75 08/01/08 00 01/01/07

E2394 DRIVE WHEEL EXCLUDES TIRE RR $7.69 08/01/08 00 01/01/07

E2394 DRIVE WHEEL EXCLUDES TIRE UE $57.57 08/01/08 00 01/01/07


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2395 CASTER WHEEL EXCLUDES TIRE NU $54.55 08/01/08 00 01/01/07

E2395 CASTER WHEEL EXCLUDES TIRE RR $5.46 08/01/08 00 01/01/07

E2395 CASTER WHEEL EXCLUDES TIRE UE $40.93 08/01/08 00 01/01/07

E2396 CASTER FORK NU $56.53 01/01/07 00 01/01/07

E2396 CASTER FORK RR $7.13 01/01/07 00 01/01/07

E2396 CASTER FORK UE $42.41 01/01/07 00 01/01/07

E2397 Pwc acc lith-based battery NU $0.00 01/01/08 01 01/01/08

E2399 NOC INTERFACE $0.00 01/01/04 01 01/01/04

E2402 NEG PRESS WOUND THERAPY PUMP RR $1,716.46 01/01/04 01 01/01/04

E2500 SGD DIGITIZED PRE-REC <=8MIN NU $391.06 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2500 SGD DIGITIZED PRE-REC <=8MIN RR $39.11 08/01/08 01 08/01/08

E2500 SGD DIGITIZED PRE-REC <=8MIN UE $293.29 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2502 SGD PREREC MSG >8MIN <=20MIN NU $1,195.80 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2502 SGD PREREC MSG >8MIN <=20MIN RR $119.59 08/01/08 01 08/01/08

E2502 SGD PREREC MSG >8MIN <=20MIN UE $896.86 08/01/08 01 08/01/08 1 unit / 60 MO RR excluded)

E2504 SGD PREREC MSG>20MIN <=40MIN NU $1,577.42 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2504 SGD PREREC MSG>20MIN <=40MIN RR $157.76 08/01/08 01 08/01/08

E2504 SGD PREREC MSG>20MIN <=40MIN UE $1,183.05 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2506 SGD PREREC MSG > 40 MIN NU $2,312.96 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2506 SGD PREREC MSG > 40 MIN RR $231.29 08/01/08 01 08/01/08

E2506 SGD PREREC MSG > 40 MIN UE $1,734.69 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2508 SGD SPELLING PHYS CONTACT NU $3,576.61 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2508 SGD SPELLING PHYS CONTACT RR $357.67 08/01/08 01 08/01/08

E2508 SGD SPELLING PHYS CONTACT UE $2,682.47 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2510 SGD W MULTI METHODS MSG/ACCS NU $6,768.25 01/01/08 01 01/01/08 1 unit / 60 MO (RR excluded)

E2510 SGD W MULTI METHODS MSG/ACCS RR $676.82 01/01/08 01 01/01/08

E2510 SGD W MULTI METHODS MSG/ACCS UE $5,076.18 01/01/08 01 01/01/08 1 unit / 60 MO (RR excluded)

E2511 SGD SFTWRE PRGRM FOR PC/PDA $0.00 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2512 SGD ACCESSORY, MOUNTING SYS $0.00 08/01/08 01 08/01/08 1 unit / 60 MO (RR excluded)

E2599 SGD ACCESSORY NOC $0.00 08/01/08 01 08/01/08

E2601 GEN W/C CUSHION WDTH < 22 IN NU $88.65 01/01/05 01 01/01/05

E2601 GEN W/C CUSHION WDTH < 22 IN RR $8.86 01/01/05 01 01/01/05

E2601 GEN W/C CUSHION WDTH < 22 IN UE $66.49 01/01/05 01 01/01/05

E2602 GEN W/C CUSHION WDTH >=22 IN NU $161.88 01/01/05 01 01/01/05

E2602 GEN W/C CUSHION WDTH >=22 IN RR $16.20 01/01/05 01 01/01/05

E2602 GEN W/C CUSHION WDTH >=22 IN UE $121.43 01/01/05 01 01/01/05

E2603 SKIN PROTECT WC CUS WD <22IN NU $223.04 01/01/05 01 01/01/05

E2603 SKIN PROTECT WC CUS WD <22IN RR $22.31 01/01/05 01 01/01/05

E2603 SKIN PROTECT WC CUS WD <22IN UE $167.28 01/01/05 01 01/01/05

E2604 SKIN PROTECT WC CUS WD>=22IN NU $315.76 01/01/05 01 01/01/05


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2604 SKIN PROTECT WC CUS WD>=22IN RR $31.56 01/01/05 01 01/01/05

E2604 SKIN PROTECT WC CUS WD>=22IN UE $236.83 01/01/05 01 01/01/05

E2605 POSITION WC CUSH WDTH <22 IN NU $321.69 01/01/05 01 01/01/05

E2605 POSITION WC CUSH WDTH <22 IN RR $32.19 01/01/05 01 01/01/05

E2605 POSITION WC CUSH WDTH <22 IN UE $241.29 01/01/05 01 01/01/05

E2606 POSITION WC CUSH WDTH>=22 IN NU $436.07 01/01/05 01 01/01/05

E2606 POSITION WC CUSH WDTH>=22 IN RR $43.61 01/01/05 01 01/01/05

E2606 POSITION WC CUSH WDTH>=22 IN UE $327.06 01/01/05 01 01/01/05

E2607 SKIN PRO/POS WC CUS WD <22IN NU $295.60 01/01/05 01 01/01/05

E2607 SKIN PRO/POS WC CUS WD <22IN RR $29.56 01/01/05 01 01/01/05

E2607 SKIN PRO/POS WC CUS WD <22IN UE $221.70 01/01/05 01 01/01/05

E2608 SKIN PRO/POS WC CUS WD>=22IN NU $354.00 01/01/05 01 01/01/05

E2608 SKIN PRO/POS WC CUS WD>=22IN RR $35.42 01/01/05 01 01/01/05

E2608 SKIN PRO/POS WC CUS WD>=22IN UE $265.51 01/01/05 01 01/01/05

E2609 CUSTOM FABRICATE W/C CUSHION NU $0.00 09/02/08 01 01/01/05

E2609 CUSTOM FABRICATE W/C CUSHION RR $0.00 09/02/08 01 01/01/05

E2609 CUSTOM FABRICATE W/C CUSHION UE $0.00 09/02/08 01 01/01/05

E2610 POWERED W/C CUSHION $0.00 01/01/05 01 01/01/05

E2611 GEN USE BACK CUSH WDTH <22IN NU $312.35 01/01/05 01 01/01/05

E2611 GEN USE BACK CUSH WDTH <22IN RR $31.23 01/01/05 01 01/01/05

E2611 GEN USE BACK CUSH WDTH <22IN UE $234.29 01/01/05 01 01/01/05

E2612 GEN USE BACK CUSH WDTH>=22IN NU $422.54 01/01/05 01 01/01/05

E2612 GEN USE BACK CUSH WDTH>=22IN RR $42.25 01/01/05 01 01/01/05

E2612 GEN USE BACK CUSH WDTH>=22IN UE $316.87 01/01/05 01 01/01/05

E2613 POSITION BACK CUSH WD <22IN NU $393.04 01/01/05 01 01/01/05

E2613 POSITION BACK CUSH WD <22IN RR $39.31 01/01/05 01 01/01/05

E2613 POSITION BACK CUSH WD <22IN UE $294.78 01/01/05 01 01/01/05

E2614 POSITION BACK CUSH WD>=22IN NU $543.93 01/01/05 01 01/01/05

E2614 POSITION BACK CUSH WD>=22IN RR $54.40 01/01/05 01 01/01/05

E2614 POSITION BACK CUSH WD>=22IN UE $407.97 01/01/05 01 01/01/05

E2615 POS BACK POST/LAT WDTH <22IN NU $452.32 01/01/05 01 01/01/05

E2615 POS BACK POST/LAT WDTH <22IN RR $45.24 01/01/05 01 01/01/05

E2615 POS BACK POST/LAT WDTH <22IN UE $339.23 01/01/05 01 01/01/05

E2616 POS BACK POST/LAT WDTH>=22IN NU $608.58 01/01/05 01 01/01/05

E2616 POS BACK POST/LAT WDTH>=22IN RR $60.86 01/01/05 01 01/01/05

E2616 POS BACK POST/LAT WDTH>=22IN UE $456.45 01/01/05 01 01/01/05

E2617 CUSTOM FAB W/C BACK CUSHION NU $0.00 09/02/08 01 01/01/05

E2617 CUSTOM FAB W/C BACK CUSHION RR $0.00 09/02/08 01 01/01/05

E2617 CUSTOM FAB W/C BACK CUSHION UE $0.00 09/02/08 01 01/01/05

E2619 REPLACE COVER W/C SEAT CUSH NU $51.32 01/01/05 01 01/01/05


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

E2619 REPLACE COVER W/C SEAT CUSH RR $5.13 01/01/05 01 01/01/05

E2619 REPLACE COVER W/C SEAT CUSH UE $38.51 01/01/05 01 01/01/05

E2620 WC PLANAR BACK CUSH WD <22IN NU $574.76 01/01/05 01 01/01/05

E2620 WC PLANAR BACK CUSH WD <22IN RR $57.47 01/01/05 01 01/01/05

E2620 WC PLANAR BACK CUSH WD <22IN UE $431.08 01/01/05 01 01/01/05

E2621 WC PLANAR BACK CUSH WD>=22IN NU $547.70 01/01/05 01 01/01/05

E2621 WC PLANAR BACK CUSH WD>=22IN RR $54.77 01/01/05 01 01/01/05

E2621 WC PLANAR BACK CUSH WD>=22IN UE $410.79 01/01/05 01 01/01/05

K0001 STANDARD WHEELCHAIR NU $318.66 01/01/80 00 11/01/01 1 unit / 60 MO (RR excluded) + UVSP = 1

K0001 STANDARD WHEELCHAIR RR $53.11 01/01/80 00 11/01/01

K0002 STND HEMI (LOW SEAT) WHLCHR NU $490.98 01/01/80 00 01/01/94

K0002 STND HEMI (LOW SEAT) WHLCHR RR $81.83 01/01/80 00 01/01/94

K0003 LIGHTWEIGHT WHEELCHAIR NU $478.56 01/01/83 00 01/01/94

K0003 LIGHTWEIGHT WHEELCHAIR RR $79.76 01/01/80 00 01/01/94

K0004 HIGH STRENGTH LTWT WHLCHR NU $801.84 01/01/80 00 01/01/94

K0004 HIGH STRENGTH LTWT WHLCHR RR $133.64 01/01/80 00 01/01/94

K0005 ULTRALIGHTWEIGHT WHEELCHAIR NU $1,817.84 01/01/80 01 01/01/94

K0005 ULTRALIGHTWEIGHT WHEELCHAIR RR $181.78 01/01/80 01 01/01/94

K0005 ULTRALIGHTWEIGHT WHEELCHAIR UE $1,363.39 01/01/80 01 01/01/94

K0006 HEAVY DUTY WHEELCHAIR NU $752.46 01/01/80 01 11/01/01

K0006 HEAVY DUTY WHEELCHAIR RR $125.41 01/01/80 01 11/01/01

K0007 EXTRA HEAVY DUTY WHEELCHAIR NU $1,014.78 01/01/80 01 11/01/01

K0007 EXTRA HEAVY DUTY WHEELCHAIR RR $169.13 01/01/80 01 11/01/01

K0009 OTHER MANUAL WHEELCHAIR/BASE $0.00 01/01/80 01 01/01/94

K0010 STND WT FRAME POWER WHLCHR NU $4,259.90 01/01/80 01 11/01/01

K0010 STND WT FRAME POWER WHLCHR RR $425.99 01/01/80 01 11/01/01

K0011 STND WT PWR WHLCHR W CONTROL NU $5,034.80 01/01/80 01 01/01/94

K0011 STND WT PWR WHLCHR W CONTROL RR $503.48 01/01/80 01 01/01/94

K0012 LTWT PORTBL POWER WHLCHR NU $3,088.40 01/01/80 01 01/01/94

K0012 LTWT PORTBL POWER WHLCHR RR $308.84 01/01/80 01 01/01/94

K0014 OTHER POWER WHLCHR BASE $0.00 01/01/80 01 01/01/94

K0015 DETACH NON-ADJUS HGHT ARMRST NU $178.67 01/01/80 01 11/01/01

K0015 DETACH NON-ADJUS HGHT ARMRST RR $17.86 01/01/80 01 11/01/01

K0015 DETACH NON-ADJUS HGHT ARMRST UE $134.01 01/01/80 01 11/01/01

K0017 DETACH ADJUST ARMREST BASE NU $50.25 01/01/80 01 01/01/94

K0017 DETACH ADJUST ARMREST BASE RR $5.03 01/01/80 01 01/01/94

K0017 DETACH ADJUST ARMREST BASE UE $37.68 01/01/80 01 01/01/94

K0018 DETACH ADJUST ARMRST UPPER NU $28.09 01/01/80 01 11/01/01


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

K0018 DETACH ADJUST ARMRST UPPER RR $2.80 01/01/80 01 11/01/01

K0018 DETACH ADJUST ARMRST UPPER UE $21.06 01/01/80 01 11/01/01

K0019 ARM PAD EACH NU $17.24 01/01/80 00 01/01/94

K0019 ARM PAD EACH RR $1.72 01/01/80 00 01/01/94

K0019 ARM PAD EACH UE $12.93 01/01/80 00 01/01/94

K0020 FIXED ADJUST ARMREST PAIR NU $45.67 01/01/80 00 01/01/94 2 units / 36 MO

K0020 FIXED ADJUST ARMREST PAIR RR $4.58 01/01/80 00 01/01/94 2 units / 36 MO

K0020 FIXED ADJUST ARMREST PAIR UE $34.26 01/01/80 00 01/01/94 2 units / 36 MO

K0037 HIGH MOUNT FLIP-UP FOOTREST NU $48.16 01/01/80 00 01/01/94 2 units / 36 MO

K0037 HIGH MOUNT FLIP-UP FOOTREST RR $4.30 01/01/80 00 01/01/94 2 units / 36 MO

K0037 HIGH MOUNT FLIP-UP FOOTREST UE $36.13 01/01/80 00 01/01/94 2 units / 36 MO

K0038 LEG STRAP EACH NU $23.84 01/01/80 00 01/01/94 2 units / 36 MO

K0038 LEG STRAP EACH RR $2.38 01/01/80 00 01/01/94 2 units / 36 MO

K0038 LEG STRAP EACH UE $17.88 01/01/80 00 01/01/94 2 units / 36 MO

K0039 LEG STRAP H STYLE EACH NU $52.99 01/01/80 01 01/01/94

K0039 LEG STRAP H STYLE EACH RR $5.32 01/01/80 01 01/01/94

K0039 LEG STRAP H STYLE EACH UE $39.73 01/01/80 01 01/01/94

K0040 ADJUSTABLE ANGLE FOOTPLATE NU $73.41 01/01/80 01 01/01/94 2 units / 36 MO

K0040 ADJUSTABLE ANGLE FOOTPLATE RR $7.35 01/01/80 01 01/01/94 2 units / 36 MO

K0040 ADJUSTABLE ANGLE FOOTPLATE UE $55.07 01/01/80 01 01/01/94 2 units / 36 MO

K0041 LARGE SIZE FOOTPLATE EACH NU $52.05 01/01/80 01 01/01/94

K0041 LARGE SIZE FOOTPLATE EACH RR $5.19 01/01/80 01 01/01/94

K0041 LARGE SIZE FOOTPLATE EACH UE $39.02 01/01/80 01 01/01/94

K0042 STANDARD SIZE FOOTPLATE EACH NU $30.97 01/01/80 00 01/01/94

K0042 STANDARD SIZE FOOTPLATE EACH RR $3.09 01/01/80 00 01/01/94

K0042 STANDARD SIZE FOOTPLATE EACH UE $23.22 01/01/80 00 01/01/94

K0043 FTRST LOWER EXTENSION TUBE NU $19.20 01/01/80 00 01/01/94

K0043 FTRST LOWER EXTENSION TUBE RR $1.92 01/01/80 00 01/01/94

K0043 FTRST LOWER EXTENSION TUBE UE $14.41 01/01/80 00 01/01/94

K0044 FTRST UPPER HANGER BRACKET NU $16.37 01/01/80 00 01/01/94

K0044 FTRST UPPER HANGER BRACKET RR $1.64 01/01/80 00 01/01/94

K0044 FTRST UPPER HANGER BRACKET UE $12.25 01/01/80 00 01/01/94

K0045 FOOTREST COMPLETE ASSEMBLY NU $56.62 01/01/80 01 01/01/94

K0045 FOOTREST COMPLETE ASSEMBLY RR $5.84 01/01/80 01 01/01/94

K0045 FOOTREST COMPLETE ASSEMBLY UE $42.47 01/01/80 01 01/01/94

K0046 ELEVAT LEGRST LOW EXTENSION NU $19.20 01/01/80 00 01/01/94

K0046 ELEVAT LEGRST LOW EXTENSION RR $1.92 01/01/80 00 01/01/94

K0046 ELEVAT LEGRST LOW EXTENSION UE $14.41 01/01/80 00 01/01/94

K0047 ELEVAT LEGRST UP HANGR BRACK NU $75.18 01/01/80 01 01/01/94

K0047 ELEVAT LEGRST UP HANGR BRACK RR $7.52 01/01/80 01 01/01/94


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

K0047 ELEVAT LEGRST UP HANGR BRACK UE $56.40 01/01/80 01 01/01/94

K0050 RATCHET ASSEMBLY NU $31.96 01/01/80 00 01/01/94

K0050 RATCHET ASSEMBLY RR $3.18 01/01/80 00 01/01/94

K0050 RATCHET ASSEMBLY UE $23.98 01/01/80 00 01/01/94

K0051 CAM RELESE ASSEM FTRST/LGRST NU $51.72 01/01/80 01 01/01/94

K0051 CAM RELESE ASSEM FTRST/LGRST RR $5.16 01/01/80 01 01/01/94

K0051 CAM RELESE ASSEM FTRST/LGRST UE $38.79 01/01/80 01 01/01/94

K0052 SWINGAWAY DETACH FOOTREST NU $90.90 01/01/80 01 01/01/94

K0052 SWINGAWAY DETACH FOOTREST RR $9.10 01/01/80 01 01/01/94

K0052 SWINGAWAY DETACH FOOTREST UE $68.16 01/01/80 01 01/01/94

K0053 ELEVATE FOOTREST ARTICULATE NU $100.31 01/01/80 01 01/01/94 2 units / 36 MO

K0053 ELEVATE FOOTREST ARTICULATE RR $10.04 01/01/80 01 01/01/94 2 units / 36 MO

K0053 ELEVATE FOOTREST ARTICULATE UE $75.22 01/01/80 01 01/01/94 2 units / 36 MO

K0056 SEAT HT <17 OR >=21 LTWT WC NU $93.51 01/01/80 01 01/01/94

K0056 SEAT HT <17 OR >=21 LTWT WC RR $9.36 01/01/80 01 01/01/94

K0056 SEAT HT <17 OR >=21 LTWT WC UE $70.15 01/01/80 01 01/01/94

K0065 SPOKE PROTECTORS NU $43.71 01/01/80 00 01/01/94

K0065 SPOKE PROTECTORS RR $4.36 01/01/80 00 01/01/94

K0065 SPOKE PROTECTORS UE $32.79 01/01/80 00 01/01/94

K0069 REAR WHL COMPLETE SOLID TIRE NU $98.23 01/01/80 01 01/01/94

K0069 REAR WHL COMPLETE SOLID TIRE RR $9.84 01/01/80 01 01/01/94

K0069 REAR WHL COMPLETE SOLID TIRE UE $73.68 01/01/80 01 01/01/94

K0070 REAR WHL COMPL PNEUM TIRE NU $180.11 01/01/80 01 01/01/94

K0070 REAR WHL COMPL PNEUM TIRE RR $18.02 01/01/80 01 01/01/94

K0070 REAR WHL COMPL PNEUM TIRE UE $135.09 01/01/80 01 01/01/94

K0071 FRONT CASTR COMPL PNEUM TIRE NU $107.41 01/01/80 01 01/01/94

K0071 FRONT CASTR COMPL PNEUM TIRE RR $10.77 01/01/80 01 01/01/94

K0071 FRONT CASTR COMPL PNEUM TIRE UE $80.56 01/01/80 01 01/01/94

K0072 FRNT CSTR CMPL SEM-PNEUM TIR NU $60.76 01/01/80 01 01/01/94

K0072 FRNT CSTR CMPL SEM-PNEUM TIR RR $6.08 01/01/80 01 01/01/94

K0072 FRNT CSTR CMPL SEM-PNEUM TIR UE $45.58 01/01/80 01 01/01/94

K0073 CASTER PIN LOCK EACH NU $32.90 01/01/80 00 01/01/94

K0073 CASTER PIN LOCK EACH RR $3.29 01/01/80 00 01/01/94

K0073 CASTER PIN LOCK EACH UE $24.68 01/01/80 00 01/01/94

K0077 FRONT CASTER ASSEM COMPLETE NU $57.84 01/01/80 01 01/01/94

K0077 FRONT CASTER ASSEM COMPLETE RR $5.78 01/01/80 01 01/01/94

K0077 FRONT CASTER ASSEM COMPLETE UE $43.38 01/01/80 01 01/01/94

K0098 DRIVE BELT POWER WHEELCHAIR NU $25.96 01/01/80 00 01/01/94

K0098 DRIVE BELT POWER WHEELCHAIR RR $2.61 01/01/80 00 01/01/94

K0098 DRIVE BELT POWER WHEELCHAIR UE $19.48 01/01/80 00 01/01/94


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

K0105 IV HANGER NU $97.76 01/01/80 00 01/01/94

K0105 IV HANGER RR $9.76 01/01/80 00 01/01/94

K0105 IV HANGER UE $73.34 01/01/80 00 01/01/94

K0108 W/C COMPONENT-ACCESSORY NOS NU $0.00 09/02/08 01 01/01/94

K0108 W/C COMPONENT-ACCESSORY NOS RR $0.00 09/02/08 01 01/01/94

K0108 W/C COMPONENT-ACCESSORY NOS UE $0.00 09/02/08 01 01/01/94

K0195 ELEVATING WHLCHAIR LEG RESTS NU $204.70 01/01/80 00 10/01/03

K0195 ELEVATING WHLCHAIR LEG RESTS RR $20.47 01/01/80 00 10/01/03

K0455 PUMP UNINTERRUPTED INFUSION RR $251.73 01/01/80 01 01/01/98

K0552 SUPPLY/EXT INF PUMP SYR TYPE NU $2.61 08/14/07 02 08/14/07 15 units / MO

K0601 REPL BATT SILVER OXIDE 1.5 V NU $1.10 04/01/03 00 04/01/03 UVSP = 9

K0602 REPL BATT SILVER OXIDE 3 V NU $6.36 04/01/03 00 04/01/03 UVSP = 9

K0603 REPL BATT ALKALINE 1.5 V NU $0.57 04/01/03 00 04/01/03 UVSP = 9

K0604 REPL BATT LITHIUM 3.6 V NU $6.09 04/01/03 00 04/01/03 UVSP = 9

K0605 REPL BATT LITHIUM 4.5 V NU $14.60 04/01/03 00 04/01/03 UVSP = 9

K0669 SEAT/BACK CUS NO SADMERC VER NU $241.74 09/01/08 00 02/01/09

K0669 SEAT/BACK CUS NO SADMERC VER RR $24.17 09/01/08 00 02/01/09

K0669 SEAT/BACK CUS NO SADMERC VER UE $181.31 09/01/08 00 02/01/09

K0672 REMOVABLE SOFT INTERFACE LE $74.92 04/01/08 00 04/01/08

K0730 CTRL DOSE INH DRUG DELIV SYS RR $172.40 07/01/06 00 07/01/05

K0733 12-24HR SEALED LEAD ACID NU $30.21 08/01/08 00 07/01/06

K0733 12-24HR SEALED LEAD ACID RR $3.04 08/01/08 00 07/01/06

K0733 12-24HR SEALED LEAD ACID UE $22.67 08/01/08 00 07/01/06

K0734 ADJ SKIN PRO W/C CUS WD<22IN NU $331.47 07/01/06 01 07/01/06

K0734 ADJ SKIN PRO W/C CUS WD<22IN RR $33.15 07/01/06 01 07/01/06

K0734 ADJ SKIN PRO W/C CUS WD<22IN UE $248.60 07/01/06 01 07/01/06

K0735 ADJ SKIN PRO WC CUS WD>=22IN NU $421.78 07/01/06 01 07/01/06

K0735 ADJ SKIN PRO WC CUS WD>=22IN RR $42.19 07/01/06 01 07/01/06

K0735 ADJ SKIN PRO WC CUS WD>=22IN UE $316.33 07/01/06 01 07/01/06

K0736 ADJ SKIN PRO/POS WC CUS<22IN NU $334.19 07/01/06 01 07/01/06

K0736 ADJ SKIN PRO/POS WC CUS<22IN RR $33.42 07/01/06 01 07/01/06

K0736 ADJ SKIN PRO/POS WC CUS<22IN UE $250.66 07/01/06 01 07/01/06

K0737 ADJ SKIN PRO/POS WC CUS>=22ö NU $423.06 07/01/06 01 07/01/06

K0737 ADJ SKIN PRO/POS WC CUS>=22ö RR $42.30 07/01/06 01 07/01/06

K0737 ADJ SKIN PRO/POS WC CUS>=22ö UE $317.29 07/01/06 01 07/01/06

K0738 PORTABLE GAS OXYGEN SYSTEM $0.00 10/01/06 00 10/01/06

K0739 REPAIR/SVC DME NON-OXYGEN EQ $0.00 04/01/09 01 04/01/09 3 units / MO

K0800 POV GROUP 1 STD UP TO 300LBS NU $1,292.77 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0800 POV GROUP 1 STD UP TO 300LBS RR $129.28 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0800 POV GROUP 1 STD UP TO 300LBS UE $969.58 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

K0801 POV GROUP 1 HD 301-450 LBS NU $2,084.22 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0801 POV GROUP 1 HD 301-450 LBS RR $208.40 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0801 POV GROUP 1 HD 301-450 LBS UE $1,563.15 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0802 POV GROUP 1 VHD 451-600 LBS NU $2,358.66 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0802 POV GROUP 1 VHD 451-600 LBS RR $235.86 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0802 POV GROUP 1 VHD 451-600 LBS UE $1,769.01 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0815 PWC GP 1 STD SEAT/BACK NU $3,516.30 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0815 PWC GP 1 STD SEAT/BACK RR $351.63 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0816 PWC GP 1 STD CAP CHAIR NU $3,367.40 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0816 PWC GP 1 STD CAP CHAIR RR $336.74 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)





K0824 PWC GP 2 HD SEAT/BACK NU $4,842.70 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0824 PWC GP 2 HD SEAT/BACK RR $484.27 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0825 PWC GP 2 HD CAP CHAIR NU $4,229.60 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0825 PWC GP 2 HD CAP CHAIR RR $422.96 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0826 PWC GP 2 VHD SEAT/BACK NU $6,269.30 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0826 PWC GP 2 VHD SEAT/BACK RR $626.93 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0827 PWC GP VHD CAP CHAIR NU $4,809.30 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0827 PWC GP VHD CAP CHAIR RR $480.93 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0828 PWC GP 2 XTRA HD SEAT/BACK NU $6,908.20 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0828 PWC GP 2 XTRA HD SEAT/BACK RR $690.82 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0829 PWC GP 2 XTRA HD CAP CHAIR NU $6,011.80 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0829 PWC GP 2 XTRA HD CAP CHAIR RR $601.18 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0835 PWC GP2 STD SING POW OPT S/B NU $4,122.30 11/15/06 01 11/15/06 1 unit / 60 MO RR excluded)

K0835 PWC GP2 STD SING POW OPT S/B RR $412.23 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0841 PWC GP2 STD MULT POW OPT S/B NU $4,318.60 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0841 PWC GP2 STD MULT POW OPT S/B RR $431.86 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0843 PWC GP2 HD MULT POW OPT S/B NU $5,199.60 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0843 PWC GP2 HD MULT POW OPT S/B RR $519.96 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)





K0850 PWC GP 3 HD SEAT/BACK NU $6,139.90 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)


K0851 PWC GP 3 HD CAP CHAIR NU $5,741.40 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0851 PWC GP 3 HD CAP CHAIR RR $574.14 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

K0852 PWC GP 3 VHD SEAT/BACK NU $7,082.60 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)


K0853 PWC GP 3 VHD CAP CHAIR NU $7,275.60 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0853 PWC GP 3 VHD CAP CHAIR RR $727.56 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0854 PWC GP 3 XHD SEAT/BACK NU $9,638.60 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0854 PWC GP 3 XHD SEAT/BACK RR $963.86 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0855 PWC GP 3 XHD CAP CHAIR NU $9,105.10 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0855 PWC GP 3 XHD CAP CHAIR RR $910.51 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0856 PWC GP3 STD SING POW OPT S/B NU $5,672.30 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)


K0857 PWC GP3 STD SING POW OPT CAP NU $5,786.00 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0857 PWC GP3 STD SING POW OPT CAP RR $578.60 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0858 PWC GP3 HD SING POW OPT S/B NU $7,037.60 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0858 PWC GP3 HD SING POW OPT S/B RR $703.76 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0859 PWC GP3 HD SING POW OPT CAP NU $6,538.10 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0859 PWC GP3 HD SING POW OPT CAP RR $653.81 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0860 PWC GP3 VHD SING POW OPT S/B NU $10,054.10 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0860 PWC GP3 VHD SING POW OPT S/B RR $1,005.41 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0861 PWC GP3 STD MULT POW OPT S/B NU $5,681.40 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)


K0862 PWC GP3 HD MULT POW OPT S/B NU $7,037.60 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0862 PWC GP3 HD MULT POW OPT S/B RR $703.76 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0863 PWC GP3 VHD MULT POW OPT S/B NU $10,054.10 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0863 PWC GP3 VHD MULT POW OPT S/B RR $1,005.41 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0864 PWC GP3 XHD MULT POW OPT S/B NU $12,567.50 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0864 PWC GP3 XHD MULT POW OPT S/B RR $1,256.75 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0868 PWC GP 4 STD SEAT/BACK NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)


K0869 PWC GP 4 STD CAP CHAIR NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)


K0870 PWC GP 4 HD SEAT/BACK NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)


K0871 PWC GP 4 VHD SEAT/BACK NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)


K0877 PWC GP4 STD SING POW OPT S/B NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)


K0878 PWC GP4 STD SING POW OPT CAP NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)

K0878 PWC GP4 STD SING POW OPT CAP RR $0.00 10/01/07 01 10/01/07 93 days / cal YR (NU excluded)

K0879 PWC GP4 HD SING POW OPT S/B NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)

K0879 PWC GP4 HD SING POW OPT S/B RR $0.00 10/01/07 01 10/01/07 93 days / cal YR (NU excluded)


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

K0880 PWC GP4 VHD SING POW OPT S/B NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)

K0880 PWC GP4 VHD SING POW OPT S/B RR $0.00 10/01/07 01 10/01/07 93 days / cal YR (NU excluded)

K0884 PWC GP4 STD MULT POW OPT S/B NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)


K0885 PWC GP4 STD MULT POW OPT CAP NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)

K0885 PWC GP4 STD MULT POW OPT CAP RR $0.00 10/01/07 01 10/01/07 93 days / cal YR (NU excluded)

K0886 PWC GP4 HD MULT POW S/B NU $0.00 10/01/07 01 10/01/07 1 unit / 60 MO (RR excluded)

K0886 PWC GP4 HD MULT POW S/B RR $0.00 10/01/07 01 10/01/07 93 days / cal YR (NU excluded)

K0890 PWC GP5 PED SING POW OPT S/B NU $9,197.50 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0890 PWC GP5 PED SING POW OPT S/B RR $919.75 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

K0891 PWC GP5 PED MULT POW OPT S/B NU $12,180.40 11/15/06 01 11/15/06 1 unit / 60 MO (RR excluded)

K0891 PWC GP5 PED MULT POW OPT S/B RR $1,218.04 11/15/06 01 11/15/06 93 days / cal YR (NU excluded)

L0112 CRANIAL CERVICAL ORTHOSIS $1,099.77 01/01/04 01 01/01/04

L0113 CRANIAL CERVICAL TORTICOLLIS $0.00 01/01/09 01 01/01/09

L0120 CERV FLEXIBLE NON-ADJUSTABLE $26.63 01/01/80 00 10/01/06

L0130 FLEX THERMOPLASTIC COLLAR MO $133.02 01/01/80 00 10/01/06

L0140 CERVICAL SEMI-RIGID ADJUSTAB $48.19 01/01/80 00 10/01/06

L0150 CERV SEMI-RIG ADJ MOLDED CHN $108.46 01/01/80 00 10/01/06

L0160 CERV SEMI-RIG WIRE OCC/MAND $133.06 01/01/80 00 10/01/06

L0170 CERVICAL COLLAR MOLDED TO PT $641.80 01/01/80 01 01/01/86

L0172 CERV COL THERMPLAS FOAM 2 PI $119.82 01/01/80 00 10/01/06

L0174 CERV COL FOAM 2 PIECE W THOR $275.72 01/01/80 01 01/01/88

L0180 CER POST COL OCC/MAN SUP ADJ $357.44 01/01/80 01 01/01/84

L0190 CERV COLLAR SUPP ADJ CERV BA $497.18 01/01/80 01 01/01/82

L0200 CERV COL SUPP ADJ BAR & THOR $518.30 01/01/80 01 01/01/84

L0220 THOR RIB BELT CUSTOM FABRICA $92.19 01/01/80 00 10/01/06

L0430 DEWALL POSTURE PROTECTOR $1,212.41 01/01/80 01 01/01/88

L0450 TLSO FLEX PREFAB THORACIC $174.44 01/01/80 00 10/01/06

L0452 TLSO FLEX CUSTOM FAB THORACI $330.85 01/01/80 01 01/01/03

L0454 TLSO FLEX PREFAB SACROCOC-T9 $350.83 01/01/80 01 01/01/03

L0456 TLSO FLEX PREFAB $350.83 01/01/80 01 01/01/03

L0458 TLSO 2MOD SYMPHIS-XIPHO PRE $547.13 01/01/80 01 01/01/03

L0460 TLSO2MOD SYMPHYSIS-STERN PRE $547.13 01/01/80 01 01/01/03

L0462 TLSO 3MOD SACRO-SCAP PRE $547.13 01/01/80 01 01/01/03

L0464 TLSO 4MOD SACRO-SCAP PRE $547.13 01/01/80 01 01/01/03

L0466 TLSO RIGID FRAME PRE SOFT AP $374.99 01/01/80 01 01/01/03

L0468 TLSO RIGID FRAME PREFAB PELV $454.50 01/01/80 01 01/01/03

L0470 TLSO RIGID FRAME PRE SUBCLAV $639.90 01/01/80 01 01/01/03

L0472 TLSO RIGID FRAME HYPEREX PRE $405.83 01/01/80 01 01/01/03


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L0480 TLSO RIGID PLASTIC CUSTOM FA $1,217.79 01/01/80 01 01/01/03

L0482 TLSO RIGID LINED CUSTOM FAB $1,388.76 01/01/80 01 01/01/03

L0484 TLSO RIGID PLASTIC CUST FAB $1,562.86 01/01/80 01 01/01/03

L0486 TLSO RIGIDLINED CUST FAB TWO $1,692.61 01/01/80 01 01/01/03

L0488 TLSO RIGID LINED PRE ONE PIE $1,212.41 01/01/80 01 01/01/03

L0490 TLSO RIGID PLASTIC PRE ONE $1,124.43 01/01/80 01 01/01/03

L0491 TLSO 2 PIECE RIGID SHELL $603.47 01/01/06 01 01/01/06

L0492 TLSO 3 PIECE RIGID SHELL $416.43 01/01/06 01 01/01/06

L0621 SIO FLEX PELVISACRAL PREFAB $92.55 01/01/06 00 10/01/06

L0622 SIO FLEX PELVISACRAL CUSTOM $259.29 01/01/06 01 01/01/06

L0623 SIO PANEL PREFAB $57.23 01/01/06 00 10/01/06

L0624 SIO PANEL CUSTOM $0.00 01/01/06 01 01/01/06

L0625 LO FLEXIBL L1-BELOW L5 PRE $43.27 01/01/06 00 10/01/06

L0626 LO SAG STAYS/PANELS PRE-FAB $61.25 01/01/06 00 10/01/06

L0627 LO SAGITT RIGID PANEL PREFAB $322.98 01/01/06 01 01/01/06

L0628 LO FLEX W/O RIGID STAYS PRE $65.92 01/01/06 00 10/01/06

L0629 LSO FLEX W/RIGID STAYS CUST $0.00 01/01/06 01 01/01/06

L0630 LSO POST RIGID PANEL PRE $127.26 01/01/06 00 10/01/06

L0631 LSO SAG-CORO RIGID FRAME PRE $806.64 01/01/06 01 01/01/06

L0632 LSO SAG RIGID FRAME CUST $0.00 01/01/06 01 01/01/06

L0633 LSO FLEXION CONTROL PREFAB $225.31 01/01/06 00 10/01/06

L0634 LSO FLEXION CONTROL CUSTOM $0.00 01/01/06 01 01/01/06

L0635 LSO SAGIT RIGID PANEL PREFAB $960.72 01/01/06 01 01/01/06

L0636 LSO SAGITTAL RIGID PANEL CUS $1,422.21 01/01/06 01 01/01/06

L0637 LSO SAG-CORONAL PANEL PREFAB $991.52 01/01/07 01 01/01/06

L0638 LSO SAG-CORONAL PANEL CUSTOM $1,036.35 01/01/06 01 01/01/06

L0639 LSO S/C SHELL/PANEL PREFAB $950.64 01/01/06 01 01/01/06

L0640 LSO S/C SHELL/PANEL CUSTOM $822.21 01/01/06 01 01/01/06

L0700 CTLSO A-P-L CONTROL MOLDED $2,029.13 01/01/80 01 01/01/84

L0710 CTLSO A-P-L CONTROL W/ INTER $2,096.18 01/01/80 01 01/01/84

L0810 HALO CERVICAL INTO JCKT VEST $2,588.89 01/01/80 01 01/01/86

L0820 HALO CERVICAL INTO BODY JACK $2,040.86 01/01/80 01 01/01/86

L0830 HALO CERV INTO MILWAUKEE TYP $3,147.31 01/01/80 01 01/01/86

L0859 MRI COMPATIBLE SYSTEM $917.03 01/01/06 01 01/01/06

L0861 HALO REPL LINER/INTERFACE $169.36 01/01/04 00 10/01/06

L0970 TLSO CORSET FRONT $114.71 01/01/80 00 10/01/06

L0972 LSO CORSET FRONT $103.29 01/01/80 00 10/01/06

L0974 TLSO FULL CORSET $173.70 01/01/80 00 10/01/06

L0976 LSO FULL CORSET $122.61 01/01/80 00 10/01/06

L0978 AXILLARY CRUTCH EXTENSION $193.20 01/01/80 00 10/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L0980 PERONEAL STRAPS PAIR $13.14 01/01/80 00 10/01/06

L0982 STOCKING SUPP GRIPS SET OF F $13.03 01/01/80 00 10/01/06

L0984 PROTECTIVE BODY SOCK EACH $51.46 01/01/80 00 10/01/06

L0999 ADD TO SPINAL ORTHOSIS NOS $0.00 01/01/98 01 01/01/98

L1000 CTLSO MILWAUKE INITIAL MODEL $2,037.70 01/01/80 01 01/01/86

L1001 CTLSO INFANT IMMOBILIZER $0.00 01/01/07 0 - 3 yrs 01 01/01/07

L1005 TENSION BASED SCOLIOSIS ORTH $2,514.93 01/01/02 01 01/01/02

L1010 CTLSO AXILLA SLING $57.18 01/01/80 00 10/01/06

L1020 KYPHOSIS PAD $86.75 01/01/80 00 10/01/06

L1025 KYPHOSIS PAD FLOATING $116.87 01/01/80 00 10/01/06

L1030 LUMBAR BOLSTER PAD $50.16 01/01/80 00 10/01/06

L1040 LUMBAR OR LUMBAR RIB PAD $78.30 01/01/80 00 10/01/06

L1050 STERNAL PAD $83.56 01/01/80 00 10/01/06

L1060 THORACIC PAD $95.99 01/01/80 00 10/01/06

L1070 TRAPEZIUS SLING $90.31 01/01/80 00 10/01/06

L1080 OUTRIGGER $48.04 01/01/80 00 10/01/06

L1085 OUTRIGGER BIL W/ VERT EXTENS $154.49 01/01/80 00 10/01/06

L1090 LUMBAR SLING $92.00 01/01/80 00 10/01/06

L1100 RING FLANGE PLASTIC/LEATHER $159.61 01/01/80 00 10/01/06

L1110 RING FLANGE PLAS/LEATHER MOL $256.33 01/01/80 01 01/01/86

L1120 COVERS FOR UPRIGHT EACH $39.86 01/01/80 00 10/01/06

L1200 FURNSH INITIAL ORTHOSIS ONLY $1,572.58 01/01/80 01 01/01/86

L1210 LATERAL THORACIC EXTENSION $262.62 01/01/80 01 01/01/86

L1220 ANTERIOR THORACIC EXTENSION $222.35 01/01/80 00 10/01/06

L1230 MILWAUKEE TYPE SUPERSTRUCTUR $446.81 01/01/80 01 01/01/86

L1240 LUMBAR DEROTATION PAD $77.93 01/01/80 00 10/01/06

L1250 ANTERIOR ASIS PAD $61.81 01/01/80 00 10/01/06

L1260 ANTERIOR THORACIC DEROTATION $67.60 01/01/80 00 10/01/06

L1270 ABDOMINAL PAD $77.76 01/01/80 00 10/01/06

L1280 RIB GUSSET (ELASTIC) EACH $86.58 01/01/80 00 10/01/06

L1290 LATERAL TROCHANTERIC PAD $78.89 01/01/80 00 10/01/06

L1300 BODY JACKET MOLD TO PATIENT $1,676.57 01/01/80 01 01/01/86

L1310 POST-OPERATIVE BODY JACKET $1,575.53 01/01/80 01 01/01/86

L1499 SPINAL ORTHOSIS NOS $0.00 01/01/82 01 01/01/82

L1500 THKAO MOBILITY FRAME $1,906.45 01/01/86 01 01/01/86

L1510 THKAO STANDING FRAME $1,206.10 01/01/80 01 01/01/82

L1520 THKAO SWIVEL WALKER $2,289.75 01/01/80 01 01/01/82

L1600 ABDUCT HIP FLEX FREJKA W CVR $123.26 01/01/80 00 10/01/06

L1610 ABDUCT HIP FLEX FREJKA COVR $44.06 01/01/80 00 10/01/06

L1620 ABDUCT HIP FLEX PAVLIK HARNE $125.04 01/01/80 00 10/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L1630 ABDUCT CONTROL HIP SEMI-FLEX $138.76 01/01/80 00 10/01/06

L1640 PELV BAND/SPREAD BAR THIGH C $347.34 01/01/80 01 01/01/82

L1650 HO ABDUCTION HIP ADJUSTABLE $203.36 01/01/80 00 10/01/06

L1652 HO BI THIGHCUFFS W SPRDR BAR $280.10 01/01/80 01 01/01/03

L1660 HO ABDUCTION STATIC PLASTIC $128.82 01/01/80 00 10/01/06

L1680 PELVIC & HIP CONTROL THIGH C $1,222.90 01/01/80 01 01/01/82

L1685 POST-OP HIP ABDUCT CUSTOM FA $1,193.85 01/01/80 01 01/01/88

L1686 HO POST-OP HIP ABDUCTION $915.55 01/01/80 01 01/01/89

L1690 COMBINATION BILATERAL HO $1,519.45 01/01/80 01 01/01/99

L1700 LEG PERTHES ORTH TORONTO TYP $1,532.72 01/01/80 01 01/01/82

L1710 LEGG PERTHES ORTH NEWINGTON $1,794.22 01/01/80 01 01/01/82

L1720 LEGG PERTHES ORTHOSIS TRILAT $1,322.56 01/01/80 01 01/01/85

L1730 LEGG PERTHES ORTH SCOTTISH R $1,135.95 01/01/80 01 01/01/82

L1755 LEGG PERTHES PATTEN BOTTOM T $1,580.97 01/01/80 01 01/01/88

L1810 KO ELASTIC WITH JOINTS $97.80 01/01/80 00 10/01/06

L1820 KO ELAS W/ CONDYLE PADS & JO $119.08 01/01/80 00 10/01/06

L1830 KO IMMOBILIZER CANVAS LONGIT $87.80 01/01/80 00 10/01/06

L1831 KNEE ORTH POS LOCKING JOINT $231.26 01/01/04 00 10/01/06

L1832 KO ADJ JNT POS RIGID SUPPORT $546.47 01/01/80 01 01/01/89

L1834 KO W/0 JOINT RIGID MOLDED TO $736.39 01/01/80 01 01/01/89

L1836 RIGID KO WO JOINTS $104.84 01/01/80 00 10/01/06

L1840 KO DEROT ANT CRUCIATE CUSTOM $922.86 01/01/80 01 01/01/86

L1843 KO SINGLE UPRIGHT CUSTOM FIT $705.03 01/01/80 01 01/01/98

L1844 KO W/ADJ JT ROT CNTRL MOLDED $1,595.91 01/01/80 01 01/01/93

L1845 KO W/ ADJ FLEX/EXT ROTAT CUS $615.27 01/01/80 01 01/01/88

L1846 KO W ADJ FLEX/EXT ROTAT MOLD $1,065.60 01/01/80 01 01/01/88

L1847 KO ADJUSTABLE W AIR CHAMBERS $451.94 01/01/80 01 01/01/99

L1850 KO SWEDISH TYPE $288.90 01/01/80 01 01/01/82

L1860 KO SUPRACONDYLAR SOCKET MOLD $1,077.00 01/01/80 01 01/01/82

L1900 AFO SPRNG WIR DRSFLX CALF BD $229.71 01/01/80 00 10/01/06

L1902 AFO ANKLE GAUNTLET $68.86 01/01/80 00 10/01/06

L1904 AFO MOLDED ANKLE GAUNTLET $471.98 01/01/80 01 01/01/88

L1906 AFO MULTILIGAMENTUS ANKLE SU $120.70 01/01/80 00 10/01/06

L1907 AFO SUPRAMALLEOLAR CUSTOM $442.14 01/01/04 01 01/01/04

L1910 AFO SING BAR CLASP ATTACH SH $268.41 01/01/80 01 01/01/82

L1920 AFO SING UPRIGHT W/ ADJUST S $274.43 01/01/80 01 01/01/82

L1930 AFO PLASTIC $237.44 01/01/80 00 10/01/06

L1932 AFO RIG ANT TIB PREFAB TCF/= $701.18 01/01/05 01 01/01/05

L1940 AFO MOLDED TO PATIENT PLASTI $496.37 01/01/80 01 01/01/82

L1945 AFO MOLDED PLAS RIG ANT TIB $929.10 01/01/80 01 01/01/89


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L1950 AFO SPIRAL MOLDED TO PT PLAS $747.58 01/01/80 01 01/01/82

L1951 AFO SPIRAL PREFABRICATED $659.91 01/01/04 01 01/01/04

L1960 AFO POS SOLID ANK PLASTIC MO $556.33 01/01/80 01 01/01/82

L1970 AFO PLASTIC MOLDED W/ANKLE J $581.72 01/01/80 01 01/01/82

L1971 AFO W/ANKLE JOINT, PREFAB $368.30 01/01/04 01 01/01/04

L1980 AFO SING SOLID STIRRUP CALF $368.36 01/01/80 01 01/01/82

L1990 AFO DOUB SOLID STIRRUP CALF $447.39 01/01/80 01 01/01/82

L2000 KAFO SING FRE STIRR THI/CALF $1,018.01 01/01/80 01 01/01/85

L2005 KAFO SNG/DBL MECHANICAL ACT $2,828.47 01/01/05 01 01/01/05

L2010 KAFO SNG SOLID STIRRUP W/O J $928.01 01/01/80 01 01/01/86

L2020 KAFO DBL SOLID STIRRUP BAND/ $1,171.94 01/01/80 01 01/01/85

L2030 KAFO DBL SOLID STIRRUP W/O J $1,016.77 01/01/80 01 01/01/86

L2034 KAFO PLA SIN UP W/WO K/A CUS $1,574.25 07/01/06 01 01/01/06

L2035 KAFO PLASTIC PEDIATRIC SIZE $136.11 01/01/80 00 10/01/06

L2036 KAFO PLAS DOUB FREE KNEE MOL $1,669.84 01/01/80 01 01/01/88

L2037 KAFO PLAS SING FREE KNEE MOL $1,671.72 01/01/80 01 01/01/89

L2038 KAFO W/O JOINT MULTI-AXIS AN $1,228.47 01/01/80 01 01/01/89

L2040 HKAFO TORSION BIL ROT STRAPS $133.65 01/01/80 00 10/01/06

L2050 HKAFO TORSION CABLE HIP PELV $478.11 01/01/80 01 01/01/82

L2060 HKAFO TORSION BALL BEARING J $582.72 01/01/80 01 01/01/82

L2070 HKAFO TORSION UNILAT ROT STR $111.60 01/01/80 00 10/01/06

L2080 HKAFO UNILAT TORSION CABLE $361.00 01/01/80 01 01/01/86

L2090 HKAFO UNILAT TORSION BALL BR $440.10 01/01/80 01 01/01/84

L2106 AFO TIB FX CAST PLASTER MOLD $682.41 07/01/06 01 01/01/88

L2108 AFO TIB FX CAST MOLDED TO PT $991.76 01/01/80 01 01/01/88

L2112 AFO TIBIAL FRACTURE SOFT $432.04 01/01/80 01 01/01/88

L2114 AFO TIB FX SEMI-RIGID $582.57 01/01/80 01 01/01/88

L2116 AFO TIBIAL FRACTURE RIGID $714.52 01/01/80 01 01/01/88

L2126 KAFO FEM FX CAST THERMOPLAS $1,031.23 07/01/06 01 01/01/88

L2128 KAFO FEM FX CAST MOLDED TO P $1,619.84 01/01/80 01 01/01/88

L2132 KAFO FEMORAL FX CAST SOFT $625.79 01/01/80 01 01/01/88

L2134 KAFO FEM FX CAST SEMI-RIGID $970.73 01/01/80 01 01/01/88

L2136 KAFO FEMORAL FX CAST RIGID $1,186.95 01/01/80 01 01/01/88

L2180 PLAS SHOE INSERT W ANK JOINT $117.53 01/01/80 00 10/01/06

L2182 DROP LOCK KNEE $80.46 01/01/80 00 10/01/06

L2184 LIMITED MOTION KNEE JOINT $93.25 01/01/80 00 10/01/06

L2186 ADJ MOTION KNEE JNT LERMAN T $113.33 01/01/80 00 10/01/06

L2188 QUADRILATERAL BRIM $225.44 01/01/80 00 10/01/06

L2190 WAIST BELT $65.74 01/01/80 00 10/01/06

L2192 PELVIC BAND & BELT THIGH FLA $357.87 01/01/80 01 01/01/88


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L2200 LIMITED ANKLE MOTION EA JNT $47.72 01/01/80 00 10/01/06

L2210 DORSIFLEXION ASSIST EACH JOI $67.47 01/01/80 00 10/01/06

L2220 DORSI & PLANTAR FLEX ASS/RES $82.19 01/01/80 00 10/01/06

L2230 SPLIT FLAT CALIPER STIRR & P $77.01 01/01/80 00 10/01/06

L2232 ROCKER BOTTOM, CONTACT AFO $0.00 01/01/05 01 01/01/05

L2240 ROUND CALIPER AND PLATE ATTA $83.93 01/01/80 00 10/01/06

L2250 FOOT PLATE MOLDED STIRRUP AT $356.64 01/01/80 01 01/01/86

L2260 REINFORCED SOLID STIRRUP $201.20 01/01/80 00 10/01/06

L2265 LONG TONGUE STIRRUP $118.20 01/01/80 00 10/01/06

L2270 VARUS/VALGUS STRAP PADDED/LI $53.90 01/01/80 00 10/01/06

L2275 PLASTIC MOD LOW EXT PAD/LINE $117.73 01/01/80 00 10/01/06

L2280 MOLDED INNER BOOT $454.48 01/01/80 01 01/01/86

L2300 ABDUCTION BAR JOINTED ADJUST $270.23 01/01/80 01 01/01/86

L2310 ABDUCTION BAR-STRAIGHT $123.47 01/01/80 00 10/01/06

L2320 NON-MOLDED LACER $206.50 01/01/80 00 10/01/06

L2330 LACER MOLDED TO PATIENT MODE $394.10 01/01/80 01 01/01/86

L2335 ANTERIOR SWING BAND $228.01 01/01/80 00 10/01/06

L2340 PRE-TIBIAL SHELL MOLDED TO P $448.58 01/01/80 01 01/01/86

L2350 PROSTHETIC TYPE SOCKET MOLDE $894.32 01/01/80 01 01/01/86

L2360 EXTENDED STEEL SHANK $51.36 01/01/80 00 10/01/06

L2370 PATTEN BOTTOM $257.65 01/01/80 01 01/01/88

L2375 TORSION ANK & HALF SOLID STI $113.41 01/01/80 00 10/01/06

L2380 TORSION STRAIGHT KNEE JOINT $123.56 01/01/80 00 10/01/06

L2385 STRAIGHT KNEE JOINT HEAVY DU $134.43 01/01/80 00 10/01/06

L2387 ADD LE POLY KNEE CUSTOM KAFO $166.10 07/01/06 00 10/01/06

L2390 OFFSET KNEE JOINT EACH $109.86 01/01/80 00 10/01/06

L2395 OFFSET KNEE JOINT HEAVY DUTY $143.93 01/01/80 00 10/01/06

L2397 SUSPENSION SLEEVE LOWER EXT $99.48 01/01/80 00 10/01/06

L2405 KNEE JOINT DROP LOCK EA JNT $68.50 01/01/80 00 10/01/06

L2415 KNEE JOINT CAM LOCK EACH JOI $95.43 01/01/80 00 10/01/06

L2425 KNEE DISC/DIAL LOCK/ADJ FLEX $112.64 01/01/80 00 10/01/06

L2430 KNEE JNT RATCHET LOCK EA JNT $112.64 01/01/80 00 10/01/06

L2492 KNEE LIFT LOOP DROP LOCK RIN $88.98 01/01/80 00 10/01/06

L2500 THI/GLUT/ISCHIA WGT BEARING $316.63 01/01/80 01 01/01/86

L2510 TH/WGHT BEAR QUAD-LAT BRIM M $729.05 01/01/80 01 01/01/86

L2520 TH/WGHT BEAR QUAD-LAT BRIM C $462.37 01/01/80 01 01/01/86

L2525 TH/WGHT BEAR NAR M-L BRIM MO $1,142.09 01/01/80 01 01/01/89

L2526 TH/WGHT BEAR NAR M-L BRIM CU $637.51 01/01/80 01 01/01/89

L2530 THIGH/WGHT BEAR LACER NON-MO $235.82 01/01/80 00 10/01/06

L2540 THIGH/WGHT BEAR LACER MOLDED $424.34 01/01/80 01 01/01/86


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L2550 THIGH/WGHT BEAR HIGH ROLL CU $288.26 01/01/80 01 01/01/86

L2570 HIP CLEVIS TYPE 2 POSIT JNT $478.06 01/01/80 01 01/01/86

L2580 PELVIC CONTROL PELVIC SLING $465.81 01/01/80 01 01/01/86

L2600 HIP CLEVIS/THRUST BEARING FR $206.13 01/01/80 00 10/01/06

L2610 HIP CLEVIS/THRUST BEARING LO $243.74 01/01/80 00 10/01/06

L2620 PELVIC CONTROL HIP HEAVY DUT $268.36 01/01/80 01 01/01/86

L2622 HIP JOINT ADJUSTABLE FLEXION $307.79 01/01/80 01 01/01/88

L2624 HIP ADJ FLEX EXT ABDUCT CONT $332.36 01/01/80 01 01/01/88

L2627 PLASTIC MOLD RECIPRO HIP & C $1,290.44 01/01/80 01 01/01/89

L2628 METAL FRAME RECIPRO HIP & CA $1,261.16 01/01/80 01 01/01/89

L2630 PELVIC CONTROL BAND & BELT U $248.53 01/01/80 00 10/01/06

L2640 PELVIC CONTROL BAND & BELT B $337.29 01/01/80 01 01/01/86

L2650 PELV & THOR CONTROL GLUTEAL $100.65 01/01/80 00 10/01/06

L2660 THORACIC CONTROL THORACIC BA $187.06 01/01/80 00 10/01/06

L2670 THORAC CONT PARASPINAL UPRIG $153.51 01/01/80 00 10/01/06

L2680 THORAC CONT LAT SUPPORT UPRI $142.52 01/01/80 00 10/01/06

L2750 PLATING CHROME/NICKEL PR BAR $62.92 01/01/80 00 10/01/06

L2755 CARBON GRAPHITE LAMINATION $102.68 01/01/80 00 10/01/06

L2760 EXTENSION PER EXTENSION PER $60.98 01/01/80 00 10/01/06

L2768 ORTHO SIDEBAR DISCONNECT $102.38 01/01/80 00 10/01/06

L2770 LOW EXT ORTHOSIS PER BAR/JNT $61.97 01/01/80 00 10/01/06

L2780 NON-CORROSIVE FINISH $67.92 01/01/80 00 10/01/06

L2785 DROP LOCK RETAINER EACH $31.81 01/01/80 00 10/01/06

L2795 KNEE CONTROL FULL KNEECAP $85.28 01/01/80 00 10/01/06

L2800 KNEE CAP MEDIAL OR LATERAL P $107.06 01/01/80 00 10/01/06

L2810 KNEE CONTROL CONDYLAR PAD $78.39 01/01/80 00 10/01/06

L2820 SOFT INTERFACE BELOW KNEE SE $87.16 01/01/80 00 10/01/06

L2830 SOFT INTERFACE ABOVE KNEE SE $94.30 01/01/80 00 10/01/06

L2840 TIBIAL LENGTH SOCK FX OR EQU $32.89 01/01/80 00 10/01/06

L2850 FEMORAL LGTH SOCK FX OR EQUA $56.34 01/01/80 00 10/01/06

L2999 LOWER EXTREMITY ORTHOSIS NOS $0.00 01/01/80 01 01/01/82

L3000 FT INSERT UCB BERKELEY SHELL $246.83 07/01/06 00 10/01/06

L3001 FOOT INSERT REMOV MOLDED SPE $85.00 01/01/80 00 10/01/06

L3002 FOOT INSERT PLASTAZOTE OR EQ $126.90 07/01/06 00 10/01/06

L3003 FOOT INSERT SILICONE GEL EAC $136.92 07/01/06 00 10/01/06

L3010 FOOT LONGITUDINAL ARCH SUPPO $136.92 07/01/06 00 10/01/06

L3020 FOOT LONGITUD/METATARSAL SUP $155.91 07/01/06 00 10/01/06

L3030 FOOT ARCH SUPPORT REMOV PREM $59.97 07/01/06 00 10/01/06

L3040 FT ARCH SUPRT PREMOLD LONGIT $36.97 07/01/06 00 10/01/06

L3050 FOOT ARCH SUPP PREMOLD METAT $36.97 07/01/06 00 10/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L3060 FOOT ARCH SUPP LONGITUD/META $57.97 07/01/06 00 10/01/06

L3070 ARCH SUPRT ATT TO SHO LONGIT $24.96 07/01/06 00 10/01/06

L3080 ARCH SUPP ATT TO SHOE METATA $24.96 07/01/06 00 10/01/06

L3090 ARCH SUPP ATT TO SHOE LONG/M $31.99 07/01/06 00 10/01/06

L3100 HALLUS-VALGUS NGHT DYNAMIC S $33.97 07/01/06 00 10/01/06

L3140 ABDUCTION ROTATION BAR SHOE $33.00 01/01/80 00 10/01/06

L3150 ABDUCT ROTATION BAR W/O SHOE $33.00 01/01/80 00 10/01/06

L3160 SHOE STYLED POSITIONING DEV $11.86 07/01/06 00 10/01/06

L3170 FOOT PLASTIC HEEL STABILIZER $39.99 07/01/06 00 10/01/06

L3201 OXFORD W SUPINAT/PRONAT INF $42.50 01/01/80 00 01/01/84

L3202 OXFORD W/ SUPINAT/PRONATOR C $42.50 01/01/80 00 01/01/84

L3203 OXFORD W/ SUPINATOR/PRONATOR $42.50 01/01/80 00 01/01/84

L3204 HIGHTOP W/ SUPP/PRONATOR INF $42.50 01/01/80 00 01/01/84

L3206 HIGHTOP W/ SUPP/PRONATOR CHI $42.50 01/01/80 00 01/01/84

L3207 HIGHTOP W/ SUPP/PRONATOR JUN $42.50 01/01/80 00 01/01/84

L3208 SURGICAL BOOT EACH INFANT $23.72 07/01/06 00 10/01/06

L3209 SURGICAL BOOT EACH CHILD $33.60 07/01/06 00 10/01/06

L3211 SURGICAL BOOT EACH JUNIOR $35.97 07/01/06 00 10/01/06

L3212 BENESCH BOOT PAIR INFANT $50.20 07/01/06 00 10/01/06

L3213 BENESCH BOOT PAIR CHILD $60.48 07/01/06 00 10/01/06

L3214 BENESCH BOOT PAIR JUNIOR $64.43 07/01/06 00 10/01/06

L3215 ORTHOPEDIC FTWEAR LADIES OXF $47.50 01/01/80 00 01/01/84

L3217 LADIES SHOES HIGHTOP DEPTH I $47.50 01/01/80 00 01/01/84

L3219 ORTHOPEDIC MENS SHOES OXFORD $62.50 01/01/80 00 01/01/84

L3221 ORTHOPEDIC MENS SHOES DPTH I $62.50 01/01/80 00 01/01/84

L3222 MENS SHOES HIGHTOP DEPTH INL $62.50 01/01/80 00 01/01/84

L3224 WOMAN'S SHOE OXFORD BRACE $47.50 01/01/80 00 01/01/95

L3225 MAN'S SHOE OXFORD BRACE $67.89 01/01/80 00 01/01/04

L3230 CUSTOM SHOES DEPTH INLAY $157.41 01/01/05 00 10/01/06

L3250 CUSTOM MOLD SHOE REMOV PROST $278.67 07/01/06 01 01/01/84

L3251 SHOE MOLDED TO PT SILICONE S $38.34 07/01/06 00 10/01/06

L3252 SHOE MOLDED PLASTAZOTE CUST $152.57 07/01/06 00 10/01/06

L3253 SHOE MOLDED PLASTAZOTE CUST $38.34 07/01/06 00 01/01/84

L3254 ORTH FOOT NON-STNDARD SIZE/W $0.00 01/01/80 01 06/01/09

L3255 ORTH FOOT NON-STANDARD SIZE/ $0.00 01/01/80 01 06/01/09

L3257 ORTH FOOT ADD CHARGE SPLIT S $27.67 07/01/06 00 01/01/88

L3260 AMBULATORY SURGICAL BOOT EAC $15.42 07/01/06 00 01/01/84

L3265 PLASTAZOTE SANDAL EACH $17.00 07/01/06 00 01/01/84

L3300 SHO LIFT TAPER TO METATARSAL $40.97 07/01/06 00 01/01/86

L3310 SHOE LIFT ELEV HEEL/SOLE NEO $63.96 07/01/06 00 01/01/86


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L3320 SHOE LIFT ELEV HEEL/SOLE COR $103.17 07/01/06 00 01/01/86

L3330 LIFTS ELEVATION METAL EXTENS $444.70 07/01/06 01 06/01/07

L3332 SHOE LIFTS TAPERED TO ONE-HA $57.97 07/01/06 00 01/01/86 1 unit per foot per CAL YR

L3334 SHOE LIFTS ELEVATION HEEL /I $29.98 07/01/06 00 01/01/86

L3340 SHOE WEDGE SACH $66.96 07/01/06 00 01/01/82

L3350 SHOE HEEL WEDGE $18.00 07/01/06 00 01/01/82

L3360 SHOE SOLE WEDGE OUTSIDE SOLE $27.98 07/01/06 00 01/01/84

L3370 SHOE SOLE WEDGE BETWEEN SOLE $38.95 07/01/06 00 01/01/84

L3380 SHOE CLUBFOOT WEDGE $38.95 07/01/06 00 01/01/82

L3390 SHOE OUTFLARE WEDGE $38.95 07/01/06 00 01/01/82

L3400 SHOE METATARSAL BAR WEDGE RO $31.99 07/01/06 00 01/01/84

L3410 SHOE METATARSAL BAR BETWEEN $72.94 07/01/06 00 01/01/84

L3420 FULL SOLE/HEEL WEDGE BTWEEN $42.97 07/01/06 00 01/01/84

L3430 SHO HEEL COUNT PLAST REINFOR $125.92 07/01/06 00 01/01/85

L3440 HEEL LEATHER REINFORCED $59.97 07/01/06 00 01/01/84

L3450 SHOE HEEL SACH CUSHION TYPE $82.94 07/01/06 00 01/01/84

L3455 SHOE HEEL NEW LEATHER STANDA $31.99 07/01/06 00 01/01/84

L3460 SHOE HEEL NEW RUBBER STANDAR $26.97 07/01/06 00 01/01/84

L3465 SHOE HEEL THOMAS WITH WEDGE $10.00 01/01/80 00 01/01/84

L3470 SHOE HEEL THOMAS EXTEND TO B $48.96 07/01/06 00 01/01/84

L3480 SHOE HEEL PAD & DEPRESS FOR $48.96 07/01/06 00 01/01/84

L3485 SHOE HEEL PAD REMOVABLE FOR $15.42 07/01/06 00 01/01/84

L3500 ORTHO SHOE ADD LEATHER INSOL $22.98 07/01/06 00 01/01/86

L3510 ORTHOPEDIC SHOE ADD RUB INSL $22.98 07/01/06 00 01/01/86

L3520 O SHOE ADD FELT W LEATH INSL $24.96 07/01/06 00 01/01/86

L3530 ORTHO SHOE ADD HALF SOLE $24.96 07/01/06 00 01/01/86

L3540 ORTHO SHOE ADD FULL SOLE $39.99 07/01/06 00 01/01/86

L3550 O SHOE ADD STANDARD TOE TAP $6.98 07/01/06 00 01/01/86

L3560 O SHOE ADD HORSESHOE TOE TAP $18.00 07/01/06 00 01/01/86

L3570 O SHOE ADD INSTEP EXTENSION $66.96 07/01/06 00 01/01/86

L3580 O SHOE ADD INSTEP VELCRO CLO $50.96 07/01/06 00 01/01/86

L3590 O SHOE CONVERT TO SOF COUNTE $41.97 07/01/06 00 01/01/86

L3595 ORTHO SHOE ADD MARCH BAR $32.97 07/01/06 00 01/01/86

L3600 TRANS SHOE CALIP PLATE EXIST $59.97 07/01/06 00 10/01/06

L3610 TRANS SHOE CALIPER PLATE NEW $78.94 07/01/06 00 10/01/06

L3620 TRANS SHOE SOLID STIRRUP EXI $59.97 07/01/06 00 10/01/06

L3630 TRANS SHOE SOLID STIRRUP NEW $78.94 07/01/06 00 10/01/06

L3640 SHOE DENNIS BROWNE SPLINT BO $33.97 07/01/06 00 10/01/06

L3649 ORTHOPEDIC SHOE MODIFICA NOS $0.00 01/01/80 01 01/01/82

L3650 SHLDER FIG 8 ABDUCT RESTRAIN $58.25 01/01/86 00 10/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L3660 ABDUCT RESTRAINER CANVAS&WEB $89.62 01/01/80 00 10/01/06

L3670 ACROMIO/CLAVICULAR CANVAS&WE $111.06 01/01/80 00 10/01/06

L3671 SO CAP DESIGN W/O JNTS CF $644.37 07/01/06 01 01/01/06

L3672 SO AIRPLANE W/O JNTS CF $801.31 07/01/06 01 01/01/06

L3673 SO AIRPLANE W/JOINT CF $873.35 07/01/06 01 01/01/06

L3675 CANVAS VEST SO $125.49 01/01/80 00 10/01/06

L3677 SO HARD PLASTIC STABILIZER $67.87 01/01/80 00 01/01/02

L3702 EO W/O JOINTS CF $206.49 07/01/06 00 10/01/06

L3710 ELBOW ELASTIC WITH METAL JOI $101.95 01/01/80 00 10/01/06

L3720 FOREARM/ARM CUFFS FREE MOTIO $642.40 01/01/80 01 01/01/84

L3730 FOREARM/ARM CUFFS EXT/FLEX A $885.36 01/01/80 01 01/01/82

L3740 CUFFS ADJ LOCK W/ ACTIVE CON $1,049.67 01/01/80 01 01/01/82

L3760 EO WITHJOINT, PREFABRICATED $357.62 01/01/80 01 01/01/01

L3762 RIGID EO WO JOINTS $76.89 01/01/80 00 10/01/06

L3763 EWHO RIGID W/O JNTS CF $916.94 07/01/06 01 01/01/06

L3764 EWHO W/JOINT(S) CF $970.98 07/01/06 01 01/01/06

L3765 EWHFO RIGID W/O JNTS CF $916.94 07/01/06 01 01/01/06

L3766 EWHFO W/JOINT(S) CF $970.98 07/01/06 01 01/01/06

L3806 WHFO W/JOINT(S) CUSTOM FAB $0.00 01/01/07 01 06/01/09

L3807 WHFO,NO JOINT, PREFABRICATED $178.81 01/01/80 00 10/01/06

L3808 WHFO RIGID W/O JOINTS $0.00 01/01/07 01 06/01/09

L3900 HINGE EXTENSION/FLEX WRIST/F $1,166.95 01/01/86 01 01/01/86

L3901 HINGE EXT/FLEX WRIST FINGER $1,436.40 01/01/80 01 01/01/84

L3904 WHFO ELECTRIC CUSTOM FITTED $2,876.16 01/01/80 01 01/01/82

L3905 WHO W/NONTORSION JNT(S) CF $709.19 07/01/06 01 01/01/06

L3906 WHO W/O JOINTS CF $388.08 01/01/80 01 01/01/86

L3908 WRIST COCK-UP NON-MOLDED $58.85 01/01/80 00 01/01/86

L3912 FLEX GLOVE W/ELASTIC FINGER $93.14 01/01/80 00 10/01/06

L3913 HFO W/O JOINTS CF $193.69 07/01/06 00 10/01/06

L3915 WHO W NONTOR JNT(S) PREFAB $0.00 01/01/07 01 06/01/09

L3917 PREFAB METACARPL FX ORTHOSIS $75.54 01/01/04 00 10/01/06

L3919 HO W/O JOINTS CF $193.69 07/01/06 00 10/01/06

L3921 HFO W/JOINT(S) CF $229.71 07/01/06 00 10/01/06

L3923 HFO W/O JOINTS PF $27.82 01/01/80 00 10/01/06

L3925 FO pip/dip with joint/spring $50.31 01/01/08 00 01/01/08

L3927 FO pip/dip w/o joint/spring $0.00 01/01/08 01 01/01/08

L3929 HFO nontorsion joint prefab $82.24 01/01/08 00 01/01/08

L3931 WHFO nontorsion joint prefab $183.67 01/01/08 00 01/01/08

L3933 FO W/O JOINTS CF $152.58 07/01/06 00 10/01/06

L3935 FO NONTORSION JOINT CF $157.98 07/01/06 00 10/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L3956 ADD JOINT UPPER EXT ORTHOSIS $0.00 01/01/97 01 01/01/97

L3960 SEWHO AIRPLAN DESIG ABDU POS $721.81 09/01/03 01 01/01/86

L3961 SEWHO CAP DESIGN W/O JNTS CF $1,201.47 07/01/06 01 01/01/06

L3962 SEWHO ERBS PALSEY DESIGN ABD $704.68 07/01/06 01 01/01/82

L3964 SEO MOBILE ARM SUP ATT TO WC NU $621.11 01/01/80 01 01/01/86

L3964 SEO MOBILE ARM SUP ATT TO WC RR $62.10 01/01/80 01 01/01/86

L3964 SEO MOBILE ARM SUP ATT TO WC UE $465.80 01/01/80 01 01/01/86

L3965 ARM SUPP ATT TO WC RANCHO TY NU $991.11 01/01/80 01 01/01/84

L3965 ARM SUPP ATT TO WC RANCHO TY RR $99.13 01/01/80 01 01/01/84

L3965 ARM SUPP ATT TO WC RANCHO TY UE $743.33 01/01/80 01 01/01/84

L3966 MOBILE ARM SUPPORTS RECLININ NU $746.64 01/01/80 01 01/01/86

L3966 MOBILE ARM SUPPORTS RECLININ RR $74.67 01/01/80 01 01/01/86

L3966 MOBILE ARM SUPPORTS RECLININ UE $559.98 01/01/80 01 01/01/86

L3967 SEWHO AIRPLANE W/O JNTS CF $0.00 01/01/06 01 01/01/06

L3968 FRICTION DAMPENING ARM SUPP NU $944.86 01/01/80 01 01/01/86

L3968 FRICTION DAMPENING ARM SUPP RR $94.48 01/01/80 01 01/01/86

L3968 FRICTION DAMPENING ARM SUPP UE $708.65 01/01/80 01 01/01/86

L3969 MONOSUSPENSION ARM/HAND SUPP NU $660.74 01/01/80 01 01/01/88

L3969 MONOSUSPENSION ARM/HAND SUPP RR $66.08 01/01/80 01 01/01/88

L3969 MONOSUSPENSION ARM/HAND SUPP UE $495.54 01/01/80 01 01/01/88

L3970 ELEVAT PROXIMAL ARM SUPPORT NU $264.31 01/01/80 01 01/01/86

L3970 ELEVAT PROXIMAL ARM SUPPORT RR $26.43 01/01/80 01 01/01/86

L3970 ELEVAT PROXIMAL ARM SUPPORT UE $198.23 01/01/80 01 01/01/86

L3971 SEWHO CAP DESIGN W/JNT(S) CF $0.00 01/01/06 01 01/01/06

L3972 OFFSET/LAT ROCKER ARM W/ ELA NU $165.18 01/01/80 00 10/01/06

L3972 OFFSET/LAT ROCKER ARM W/ ELA RR $16.51 01/01/80 00 10/01/06

L3972 OFFSET/LAT ROCKER ARM W/ ELA UE $123.89 01/01/80 00 10/01/06

L3973 SEWHO AIRPLANE W/JNT(S) CF $1,418.53 07/01/06 01 01/01/06

L3974 MOBILE ARM SUPPORT SUPINATOR NU $142.55 01/01/80 00 10/01/06

L3974 MOBILE ARM SUPPORT SUPINATOR RR $14.27 01/01/80 00 10/01/06

L3974 MOBILE ARM SUPPORT SUPINATOR UE $106.91 01/01/80 00 10/01/06

L3975 SEWHFO CAP DESIGN W/O JNT CF $1,201.47 07/01/06 01 01/01/06

L3976 SEWHFO AIRPLANE W/O JNTS CF $1,201.47 07/01/06 01 01/01/06

L3977 SEWHFO CAP DESGN W/JNT(S) CF $1,346.51 07/01/06 01 01/01/06

L3978 SEWHFO AIRPLANE W/JNT(S) CF $1,418.53 07/01/06 01 01/01/06

L3980 UPP EXT FX ORTHOSIS HUMERAL $303.63 01/01/82 01 01/01/82

L3982 UPPER EXT FX ORTHOSIS RAD/UL $366.65 01/01/80 01 01/01/84

L3984 UPPER EXT FX ORTHOSIS WRIST $338.05 01/01/80 01 01/01/82

L3995 SOCK FRACTURE OR EQUAL EACH $28.06 01/01/80 00 10/01/06

L3999 UPPER LIMB ORTHOSIS NOS $0.00 01/01/82 01 01/01/82


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L4000 REPL GIRDLE MILWAUKEE ORTH $1,279.73 01/01/85 01 01/01/85

L4002 REPLACE STRAP, ANY ORTHOSIS $0.00 01/01/05 01 01/01/05

L4010 REPLACE TRILATERAL SOCKET BR $673.59 01/01/80 01 01/01/85

L4020 REPLACE QUADLAT SOCKET BRIM $864.49 01/01/80 01 01/01/85

L4030 REPLACE SOCKET BRIM CUST FIT $506.74 01/01/80 01 01/01/85

L4040 REPLACE MOLDED THIGH LACER $409.70 01/01/80 01 01/01/85

L4045 REPLACE NON-MOLDED THIGH LAC $329.24 01/01/80 01 01/01/88

L4050 REPLACE MOLDED CALF LACER $414.36 01/01/80 01 01/01/85

L4055 REPLACE NON-MOLDED CALF LACE $268.31 01/01/80 01 01/01/88

L4060 REPLACE HIGH ROLL CUFF $318.97 01/01/80 01 01/01/85

L4070 REPLACE PROX & DIST UPRIGHT $282.46 01/01/80 01 01/01/86

L4080 REPL MET BAND KAFO-AFO PROX $86.99 01/01/80 00 10/01/06

L4090 REPL MET BAND KAFO-AFO CALF/ $82.84 01/01/80 00 10/01/06

L4100 REPL LEATH CUFF KAFO PROX TH $104.69 01/01/80 00 10/01/06

L4110 REPL LEATH CUFF KAFO-AFO CAL $85.11 01/01/80 00 10/01/06

L4130 REPLACE PRETIBIAL SHELL $497.96 01/01/80 01 01/01/84

L4205 ORTHO DVC REPAIR PER 15 MIN $8.00 01/01/05 02 01/01/05 UVSP = 16

L4210 ORTH DEV REPAIR/REPL MINOR P $8.00 01/01/80 02 01/01/05 UVSP = 16

L4350 ANKLE CONTROL ORTHOSI PREFAB $89.72 01/01/89 00 10/01/06

L4360 PNEUMATI WALKING BOOT PREFAB $243.17 01/01/80 00 10/01/06

L4370 PNEUMATIC FULL LEG SPLINT $142.11 01/01/80 00 10/01/06

L4380 PNEUMATIC KNEE SPLINT $80.85 01/01/80 00 10/01/06

L4386 NON-PNEUM WALK BOOT PREFAB $124.58 01/01/80 00 10/01/06

L4392 REPLACE AFO SOFT INTERFACE $18.19 01/01/80 00 10/01/06

L4394 REPLACE FOOT DROP SPINT $13.25 01/01/80 00 10/01/06

L4396 STATIC AFO $129.66 01/01/80 00 10/01/06

L4398 FOOT DROP SPLINT RECUMBENT $59.69 01/01/80 00 10/01/06

L5000 SHO INSERT W ARCH TOE FILLER $481.95 01/01/80 01 01/01/82

L5010 MOLD SOCKET ANK HGT W/ TOE F $1,082.00 01/01/80 01 01/01/82

L5020 TIBIAL TUBERCLE HGT W/ TOE F $2,119.07 01/01/80 01 01/01/82

L5050 ANK SYMES MOLD SCKT SACH FT $2,135.36 01/01/80 01 01/01/85

L5060 SYMES MET FR LEATH SOCKET AR $2,953.39 01/01/80 01 01/01/85

L5100 MOLDED SOCKET SHIN SACH FOOT $2,156.06 01/01/80 01 01/01/82

L5105 PLAST SOCKET JTS/THGH LACER $3,714.66 01/01/80 01 01/01/89

L5150 MOLD SCKT EXT KNEE SHIN SACH $3,755.02 01/01/80 01 01/01/82

L5160 MOLD SOCKET BENT KNEE SHIN S $4,084.26 01/01/80 01 01/01/82

L5200 KNE SING AXIS FRIC SHIN SACH $3,218.43 01/01/80 01 01/01/82

L5210 NO KNEE/ANKLE JOINTS W/ FT B $2,374.61 01/01/80 01 01/01/82

L5220 NO KNEE JOINT WITH ARTIC ALI $2,949.37 01/01/80 01 01/01/82

L5230 FEM FOCAL DEFIC CONSTANT FRI $4,067.77 01/01/80 01 01/01/82


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L5250 HIP CANAD SING AXI CONS FRIC $5,548.07 01/01/80 01 01/01/82

L5270 TILT TABLE LOCKING HIP SING $5,499.47 01/01/80 01 01/01/82

L5280 HEMIPELVECT CANAD SING AXIS $5,444.47 01/01/80 01 01/01/82

L5301 BK MOLD SOCKET SACH FT ENDO $2,444.64 01/01/02 01 01/01/02

L5311 KNEE DISART, SACH FT, ENDO $3,160.04 01/01/02 01 01/01/02

L5321 AK OPEN END SACH $3,514.44 01/01/02 01 01/01/02

L5331 HIP DISART CANADIAN SACH FT $4,670.41 01/01/02 01 01/01/02

L5341 HEMIPELVECTOMY CANADIAN SACH $5,404.15 01/01/02 01 01/01/02

L5400 POSTOP DRESS & 1 CAST CHG BK $1,272.55 01/01/80 01 01/01/82

L5410 POSTOP DSG BK EA ADD CAST CH $335.08 01/01/80 01 01/01/86

L5420 POSTOP DSG & 1 CAST CHG AK/D $1,625.34 01/01/80 01 01/01/82

L5430 POSTOP DSG AK EA ADD CAST CH $452.99 01/01/80 01 01/01/86

L5450 POSTOP APP NON-WGT BEAR DSG $326.73 01/01/80 01 01/01/82

L5460 POSTOP APP NON-WGT BEAR DSG $437.30 01/01/80 01 01/01/82

L5500 INIT BK PTB PLASTER DIRECT $1,367.68 01/01/80 01 01/01/86

L5505 INIT AK ISCHAL PLSTR DIRECT $1,859.84 01/01/80 01 01/01/86

L5510 PREP BK PTB PLASTER MOLDED $1,410.83 01/01/80 01 01/01/86

L5520 PERP BK PTB THERMOPLS DIRECT $1,536.75 01/01/80 01 01/01/86

L5530 PREP BK PTB THERMOPLS MOLDED $1,846.92 01/01/80 01 01/01/86

L5535 PREP BK PTB OPEN END SOCKET $1,813.31 01/01/80 01 01/01/89

L5540 PREP BK PTB LAMINATED SOCKET $1,934.10 01/01/80 01 01/01/86

L5560 PREP AK ISCHIAL PLAST MOLDED $1,885.32 01/01/80 01 01/01/86

L5570 PREP AK ISCHIAL DIRECT FORM $2,066.95 01/01/80 01 01/01/86

L5580 PREP AK ISCHIAL THERMO MOLD $2,508.74 01/01/80 01 01/01/86

L5585 PREP AK ISCHIAL OPEN END $2,221.79 01/01/80 01 01/01/88

L5590 PREP AK ISCHIAL LAMINATED $2,570.51 01/01/80 01 01/01/86

L5595 HIP DISARTIC SACH THERMOPLS $4,305.50 01/01/80 01 01/01/89

L5600 HIP DISART SACH LAMINAT MOLD $4,754.56 01/01/80 01 01/01/89

L5610 ABOVE KNEE HYDRACADENCE $1,965.23 01/01/80 01 01/01/86

L5611 AK 4 BAR LINK W/FRIC SWING $1,589.32 01/01/80 01 01/01/89

L5613 AK 4 BAR LING W/HYDRAUL SWIG $2,620.51 01/01/80 01 01/01/89

L5614 4-BAR LINK ABOVE KNEE W/SWNG $1,328.51 01/01/80 01 01/01/94

L5616 AK UNIV MULTIPLEX SYS FRICT $1,131.75 01/01/80 01 01/01/86

L5617 AK/BK SELF-ALIGNING UNIT EA $440.50 01/01/80 01 01/01/96

L5618 TEST SOCKET SYMES $231.58 01/01/80 00 10/01/06

L5620 TEST SOCKET BELOW KNEE $234.56 01/01/80 00 10/01/06

L5622 TEST SOCKET KNEE DISARTICULA $304.02 01/01/80 01 01/01/86

L5624 TEST SOCKET ABOVE KNEE $333.46 01/01/80 01 01/01/86

L5626 TEST SOCKET HIP DISARTICULAT $438.06 01/01/80 01 01/01/86

L5628 TEST SOCKET HEMIPELVECTOMY $387.67 01/01/80 01 01/01/86


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L5629 BELOW KNEE ACRYLIC SOCKET $254.87 01/01/80 01 01/01/89

L5630 SYME TYP EXPANDABL WALL SCKT $441.86 01/01/80 01 01/01/86

L5631 AK/KNEE DISARTIC ACRYLIC SOC $352.37 01/01/80 01 01/01/89

L5632 SYMES TYPE PTB BRIM DESIGN S $189.51 01/01/80 00 10/01/06

L5634 SYMES TYPE POSTER OPENING SO $325.26 01/01/80 01 01/01/86

L5636 SYMES TYPE MEDIAL OPENING SO $204.34 01/01/80 00 10/01/06

L5637 BELOW KNEE TOTAL CONTACT $307.69 01/01/80 01 01/01/89

L5638 BELOW KNEE LEATHER SOCKET $520.39 01/01/80 01 01/01/86

L5639 BELOW KNEE WOOD SOCKET $1,198.87 01/01/80 01 01/01/89

L5640 KNEE DISARTICULAT LEATHER SO $622.22 01/01/80 01 01/01/86

L5642 ABOVE KNEE LEATHER SOCKET $496.87 01/01/80 01 01/01/86

L5643 HIP FLEX INNER SOCKET EXT FR $1,248.22 01/01/80 01 01/01/88

L5644 ABOVE KNEE WOOD SOCKET $473.68 01/01/80 01 01/01/86

L5645 BK FLEX INNER SOCKET EXT FRA $724.32 01/01/80 01 01/01/88

L5646 BELOW KNEE CUSHION SOCKET $439.41 01/01/80 01 01/01/86

L5647 BELOW KNEE SUCTION SOCKET $850.58 01/01/80 01 01/01/88

L5648 ABOVE KNEE CUSHION SOCKET $528.00 01/01/80 01 01/01/86

L5649 ISCH CONTAINMT/NARROW M-L SO $1,536.84 01/01/80 01 01/01/88

L5650 TOT CONTACT AK/KNEE DISART S $522.01 01/01/80 01 01/01/86

L5651 AK FLEX INNER SOCKET EXT FRA $963.10 01/01/80 01 01/01/88

L5652 SUCTION SUSP AK/KNEE DISART $349.64 01/01/80 01 01/01/86

L5653 KNEE DISART EXPAND WALL SOCK $522.47 01/01/80 01 01/01/86

L5654 SOCKET INSERT SYMES $326.77 01/01/80 01 01/01/86

L5655 SOCKET INSERT BELOW KNEE $283.62 01/01/80 01 01/01/86

L5656 SOCKET INSERT KNEE ARTICULAT $396.66 01/01/80 01 01/01/86

L5658 SOCKET INSERT ABOVE KNEE $301.88 01/01/80 01 01/01/86

L5661 MULTI-DUROMETER SYMES $603.22 01/01/80 01 01/01/88

L5665 MULTI-DUROMETER BELOW KNEE $547.51 01/01/88 01 01/01/88

L5666 BELOW KNEE CUFF SUSPENSION $74.85 01/01/80 00 10/01/06

L5668 SOCKET INSERT W/O LOCK LOWER $107.98 01/01/86 00 10/01/06

L5670 BK MOLDED SUPRACONDYLAR SUSP $290.15 01/01/86 01 01/01/86

L5671 BK/AK LOCKING MECHANISM $531.87 01/01/02 01 01/01/02

L5672 BK REMOVABLE MEDIAL BRIM SUS $252.77 01/01/80 01 01/01/86

L5673 SOCKET INSERT W LOCK MECH $628.47 01/01/04 01 01/01/04

L5676 BK KNEE JOINTS SINGLE AXIS P $387.48 01/01/80 01 01/01/86

L5677 BK KNEE JOINTS POLYCENTRIC P $527.22 01/01/80 01 01/01/88

L5678 BK JOINT COVERS PAIR $42.46 01/01/80 00 10/01/06

L5679 SOCKET INSERT W/O LOCK MECH $523.67 01/01/04 01 01/01/04

L5680 BK THIGH LACER NON-MOLDED $255.75 01/01/80 01 01/01/86

L5681 INTL CUSTM CONG/LATYP INSERT $1,035.59 01/01/04 01 01/01/04


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L5682 BK THIGH LACER GLUT/ISCHIA M $668.73 01/01/80 01 01/01/86

L5683 INITIAL CUSTOM SOCKET INSERT $1,035.59 01/01/04 01 01/01/04

L5684 BK FORK STRAP $51.46 01/01/80 00 10/01/06

L5685 BELOW KNEE SUS/SEAL SLEEVE $100.83 07/01/06 00 10/01/06

L5686 BK BACK CHECK $49.79 01/01/80 00 10/01/06

L5688 BK WAIST BELT WEBBING $65.31 01/01/80 00 10/01/06

L5690 BK WAIST BELT PADDED AND LIN $104.63 01/01/80 00 10/01/06

L5692 AK PELVIC CONTROL BELT LIGHT $142.08 01/01/80 00 10/01/06

L5694 AK PELVIC CONTROL BELT PAD/L $193.98 01/01/80 00 10/01/06

L5695 AK SLEEVE SUSP NEOPRENE/EQUA $174.38 01/01/80 00 10/01/06

L5696 AK/KNEE DISARTIC PELVIC JOIN $197.84 01/01/80 00 10/01/06

L5697 AK/KNEE DISARTIC PELVIC BAND $85.84 01/01/80 00 10/01/06

L5698 AK/KNEE DISARTIC SILESIAN BA $110.02 01/01/80 00 10/01/06

L5699 SHOULDER HARNESS $199.37 01/01/80 00 10/01/06

L5700 REPLACE SOCKET BELOW KNEE $2,928.30 01/01/80 01 01/01/94

L5701 REPLACE SOCKET ABOVE KNEE $3,635.72 01/01/80 01 01/01/94

L5702 REPLACE SOCKET HIP $4,645.70 01/01/80 01 01/01/94

L5703 SYMES ANKLE W/O (SACH) FOOT $1,930.50 07/01/06 01 01/01/06

L5704 CUSTOM SHAPE COVER BK $489.05 01/01/80 01 01/01/94

L5705 CUSTOM SHAPE COVER AK $802.86 01/01/80 01 01/01/94

L5706 CUSTOM SHAPE CVR KNEE DISART $795.73 01/01/80 01 01/01/94

L5707 CUSTOM SHAPE CVR HIP DISART $1,131.18 01/01/80 01 01/01/94

L5710 KNE-SHIN EXO SNG AXI MNL LOC $384.58 01/01/80 01 01/01/86

L5711 KNEE-SHIN EXO MNL LOCK ULTRA $558.34 01/01/80 01 01/01/88

L5712 KNEE-SHIN EXO FRICT SWG & ST $460.75 01/01/80 01 01/01/86

L5714 KNEE-SHIN EXO VARIABLE FRICT $400.43 01/01/80 01 01/01/86

L5716 KNEE-SHIN EXO MECH STANCE PH $779.34 01/01/80 01 01/01/86

L5718 KNEE-SHIN EXO FRCT SWG & STA $974.09 01/01/80 01 01/01/86

L5722 KNEE-SHIN PNEUM SWG FRCT EXO $870.17 01/01/80 01 01/01/86

L5724 KNEE-SHIN EXO FLUID SWING PH $1,546.65 01/01/80 01 01/01/86

L5726 KNEE-SHIN EXT JNTS FLD SWG E $1,581.69 01/01/80 01 01/01/86

L5728 KNEE-SHIN FLUID SWG & STANCE $2,544.37 01/01/80 01 01/01/86

L5780 KNEE-SHIN PNEUM/HYDRA PNEUM $1,224.24 01/01/80 01 01/01/86

L5781 LOWER LIMB PROS VACUUM PUMP $3,150.08 01/01/80 01 01/01/03

L5785 EXOSKELETAL BK ULTRALT MATER $440.52 01/01/80 01 01/01/88

L5790 EXOSKELETAL AK ULTRA-LIGHT M $709.25 01/01/80 01 01/01/88

L5795 EXOSKEL HIP ULTRA-LIGHT MATE $894.98 01/01/80 01 01/01/88

L5810 ENDOSKEL KNEE-SHIN MNL LOCK $520.60 01/01/80 01 01/01/88

L5811 ENDO KNEE-SHIN MNL LCK ULTRA $779.85 01/01/80 01 01/01/88

L5812 ENDO KNEE-SHIN FRCT SWG & ST $604.46 01/01/80 01 01/01/88


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L5814 ENDO KNEE-SHIN HYDRAL SWG PH $2,923.91 01/01/80 01 01/01/97

L5816 ENDO KNEE-SHIN POLYC MCH STA $909.37 01/01/80 01 01/01/88

L5818 ENDO KNEE-SHIN FRCT SWG & ST $1,026.87 01/01/80 01 01/01/88

L5822 ENDO KNEE-SHIN PNEUM SWG FRC $1,365.67 01/01/80 01 01/01/88

L5824 ENDO KNEE-SHIN FLUID SWING P $1,639.82 01/01/80 01 01/01/88

L5826 MINIATURE KNEE JOINT $2,458.64 01/01/80 01 01/01/98

L5828 ENDO KNEE-SHIN FLUID SWG/STA $2,933.64 01/01/80 01 01/01/88

L5830 ENDO KNEE-SHIN PNEUM/SWG PHA $2,029.01 01/01/80 01 01/01/88

L5840 MULTI-AXIAL KNEE/SHIN SYSTEM $3,236.89 01/01/80 01 01/01/94

L5845 KNEE-SHIN SYS STANCE FLEXION $1,411.11 01/01/80 01 01/01/96

L5848 KNEE-SHIN SYS HYDRAUL STANCE $846.60 01/01/80 01 01/01/03

L5850 ENDO AK/HIP KNEE EXTENS ASSI $102.59 01/01/80 00 10/01/06

L5855 MECH HIP EXTENSION ASSIST $330.23 01/01/80 01 01/01/94

L5856 ELEC KNEE-SHIN SWING/STANCE $18,899.61 01/01/05 01 01/01/05

L5857 ELEC KNEE-SHIN SWING ONLY $6,706.30 01/01/05 01 01/01/05

L5910 ENDO BELOW KNEE ALIGNABLE SY $290.45 01/01/80 01 01/01/88

L5920 ENDO AK/HIP ALIGNABLE SYSTEM $425.51 01/01/80 01 01/01/88

L5925 ABOVE KNEE MANUAL LOCK $349.76 01/01/80 01 01/01/94

L5930 HIGH ACTIVITY KNEE FRAME $2,649.95 01/01/80 01 01/01/96

L5940 ENDO BK ULTRA-LIGHT MATERIAL $427.54 01/01/80 01 01/01/88

L5950 ENDO AK ULTRA-LIGHT MATERIAL $623.94 01/01/80 01 01/01/88

L5960 ENDO HIP ULTRA-LIGHT MATERIA $773.13 01/01/80 01 01/01/88

L5962 BELOW KNEE FLEX COVER SYSTEM $628.52 01/01/80 01 01/01/94

L5964 ABOVE KNEE FLEX COVER SYSTEM $904.80 01/01/80 01 01/01/94

L5966 HIP FLEXIBLE COVER SYSTEM $1,173.04 01/01/80 01 01/01/94

L5968 MULTIAXIAL ANKLE W DORSIFLEX $2,860.96 01/01/80 01 01/01/99

L5970 FOOT EXTERNAL KEEL SACH FOOT $204.90 01/01/80 00 10/01/06

L5971 SACH FOOT, REPLACEMENT $204.90 07/01/06 00 10/01/06

L5972 FLEXIBLE KEEL FOOT $376.85 01/01/80 01 01/01/89

L5974 FOOT SINGLE AXIS ANKLE/FOOT $249.17 01/01/80 00 10/01/06

L5975 COMBO ANKLE/FOOT PROSTHESIS $364.98 01/01/80 01 01/01/99

L5976 ENERGY STORING FOOT $598.83 01/01/80 01 01/01/89

L5978 FT PROSTH MULTIAXIAL ANKL/FT $312.05 01/01/80 01 01/01/89

L5979 MULTI-AXIAL ANKLE/FT PROSTH $2,417.33 01/01/80 01 01/01/94

L5980 FLEX FOOT SYSTEM $3,384.57 01/01/80 01 01/01/89

L5981 FLEX-WALK SYS LOW EXT PROSTH $2,626.94 01/01/80 01 01/01/94

L5982 EXOSKELETAL AXIAL ROTATION U $618.17 01/01/80 01 01/01/89

L5984 ENDOSKELETAL AXIAL ROTATION $609.15 01/01/80 01 01/01/89

L5985 LWR EXT DYNAMIC PROSTH PYLON $222.32 01/01/80 00 10/01/06

L5986 MULTI-AXIAL ROTATION UNIT $677.59 01/01/80 01 01/01/89


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L5987 SHANK FT W VERT LOAD PYLON $5,663.57 01/01/80 01 01/01/97

L5988 VERTICAL SHOCK REDUCING PYLO $1,572.78 01/01/80 01 01/01/99

L5990 USER ADJUSTABLE HEEL HEIGHT $1,428.31 01/01/80 01 01/01/02

L5999 LOWR EXTREMITY PROSTHES NOS $0.00 01/01/82 01 01/01/82

L6000 PAR HAND ROBIN-AIDS THUM REM $1,420.76 01/01/82 01 01/01/82

L6010 HAND ROBIN-AIDS LITTLE/RING $1,581.07 01/01/80 01 01/01/82

L6020 PART HAND ROBIN-AIDS NO FING $1,474.10 01/01/80 01 01/01/82

L6025 PART HAND DISART MYOELECTRIC $6,300.21 01/01/80 01 01/01/03

L6050 WRST MLD SCK FLX HNG TRI PAD $2,024.81 01/01/80 01 01/01/82

L6055 WRST MOLD SOCK W/EXP INTERFA $2,596.73 01/01/80 01 01/01/88

L6100 ELB MOLD SOCK FLEX HINGE PAD $1,685.00 01/01/80 01 01/01/82

L6110 ELBOW MOLD SOCK SUSPENSION T $2,182.18 01/01/80 01 01/01/82

L6120 ELBOW MOLD DOUB SPLT SOC STE $2,477.81 01/01/80 01 01/01/82

L6130 ELBOW STUMP ACTIVATED LOCK H $2,768.09 01/01/80 01 01/01/82

L6200 ELBOW MOLD OUTSID LOCK HINGE $2,917.12 01/01/80 01 01/01/82

L6205 ELBOW MOLDED W/ EXPAND INTER $3,560.93 01/01/80 01 01/01/88

L6250 ELBOW INTER LOC ELBOW FORARM $2,871.42 01/01/80 01 01/01/82

L6300 SHLDER DISART INT LOCK ELBOW $3,983.78 01/01/80 01 01/01/82

L6310 SHOULDER PASSIVE RESTOR COMP $3,244.87 01/01/80 01 01/01/82

L6320 SHOULDER PASSIVE RESTOR CAP $1,827.35 01/01/80 01 01/01/82

L6350 THORACIC INTERN LOCK ELBOW $4,156.76 01/01/80 01 01/01/84

L6360 THORACIC PASSIVE RESTOR COMP $3,405.88 01/01/80 01 01/01/86

L6370 THORACIC PASSIVE RESTOR CAP $2,171.81 01/01/80 01 01/01/86

L6380 POSTOP DSG CAST CHG WRST/ELB $1,037.38 01/01/80 01 01/01/88

L6382 POSTOP DSG CAST CHG ELB DIS/ $1,305.03 01/01/80 01 01/01/88

L6384 POSTOP DSG CAST CHG SHLDER/T $1,692.25 01/01/80 01 01/01/88

L6386 POSTOP EA CAST CHG & REALIGN $429.41 01/01/80 01 01/01/88

L6388 POSTOP APPLICAT RIGID DSG ON $438.41 01/01/80 01 01/01/88

L6400 BELOW ELBOW PROSTH TISS SHAP $2,481.18 01/01/80 01 01/01/82

L6450 ELB DISART PROSTH TISS SHAP $3,024.44 01/01/80 01 01/01/82

L6500 ABOVE ELBOW PROSTH TISS SHAP $2,749.48 01/01/80 01 01/01/82

L6550 SHLDR DISAR PROSTH TISS SHAP $4,077.47 01/01/80 01 01/01/84

L6570 SCAP THORAC PROSTH TISS SHAP $4,680.15 01/01/80 01 01/01/84

L6580 WRIST/ELBOW BOWDEN CABLE MOL $1,433.23 01/01/80 01 01/01/88

L6582 WRIST/ELBOW BOWDEN CBL DIR F $1,103.75 01/01/80 01 01/01/88

L6584 ELBOW FAIR LEAD CABLE MOLDED $1,791.95 01/01/80 01 01/01/88

L6586 ELBOW FAIR LEAD CABLE DIR FO $1,524.30 01/01/80 01 01/01/88

L6588 SHDR FAIR LEAD CABLE MOLDED $2,593.27 01/01/80 01 01/01/88

L6590 SHDR FAIR LEAD CABLE DIRECT $2,278.38 01/01/80 01 01/01/88

L6600 POLYCENTRIC HINGE PAIR $200.57 01/01/80 00 10/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L6605 SINGLE PIVOT HINGE PAIR $198.05 01/01/80 00 10/01/06

L6610 FLEXIBLE METAL HINGE PAIR $178.02 01/01/80 00 10/01/06

L6615 DISCONNECT LOCKING WRIST UNI $146.93 01/01/80 00 10/01/06

L6616 DISCONNECT INSERT LOCKING WR $52.02 01/01/80 00 10/01/06

L6620 FLEXION/EXTENSION WRIST UNIT $306.47 01/01/80 01 01/01/86

L6621 FLEX/EXT WRIST W/WO FRICTION $1,800.78 07/01/06 01 01/01/06

L6623 SPRING-ASS ROT WRST W/ LATCH $514.43 01/01/80 01 01/01/88

L6624 FLEX/EXT/ROTATION WRIST UNIT $0.00 01/01/07 01 06/01/09

L6625 ROTATION WRST W/ CABLE LOCK $568.71 01/01/80 01 01/01/86

L6628 QUICK DISCONN HOOK ADAPTER O $384.18 01/01/80 01 01/01/88

L6629 LAMINATION COLLAR W/ COUPLIN $140.43 01/01/80 00 10/01/06

L6630 STAINLESS STEEL ANY WRIST $172.84 01/01/80 00 10/01/06

L6632 LATEX SUSPENSION SLEEVE EACH $52.10 01/01/80 00 10/01/06

L6635 LIFT ASSIST FOR ELBOW $188.33 01/01/80 00 10/01/06

L6637 NUDGE CONTROL ELBOW LOCK $343.89 01/01/80 01 01/01/88

L6638 ELEC LOCK ON MANUAL PW ELBOW $1,968.81 01/01/80 01 01/01/03

L6639 HEAVY DUTY ELBOW FEATURE $0.00 01/01/07 01 06/01/09

L6640 SHOULDER ABDUCTION JOINT PAI $224.64 01/01/80 00 10/01/06

L6641 EXCURSION AMPLIFIER PULLEY T $161.11 01/01/80 00 10/01/06

L6642 EXCURSION AMPLIFIER LEVER TY $208.95 01/01/80 00 10/01/06

L6645 SHOULDER FLEXION-ABDUCTION J $341.35 01/01/80 01 01/01/86

L6646 MULTIPO LOCKING SHOULDER JNT $2,483.11 01/01/80 01 01/01/03

L6647 SHOULDER LOCK ACTUATOR $408.79 01/01/80 01 01/01/03

L6648 EXT PWRD SHLDER LOCK/UNLOCK $2,560.98 01/01/80 01 01/01/03

L6650 SHOULDER UNIVERSAL JOINT $361.94 01/01/80 01 01/01/86

L6655 STANDARD CONTROL CABLE EXTRA $80.32 01/01/80 00 10/01/06

L6660 HEAVY DUTY CONTROL CABLE $98.15 01/01/80 00 10/01/06

L6665 TEFLON OR EQUAL CABLE LINING $39.77 01/01/80 00 10/01/06

L6670 HOOK TO HAND CABLE ADAPTER $51.28 01/01/80 00 10/01/06

L6672 HARNESS CHEST/SHLDER SADDLE $180.30 01/01/80 00 10/01/06

L6675 HARNESS FIGURE OF 8 SING CON $122.42 01/01/80 00 10/01/06

L6676 HARNESS FIGURE OF 8 DUAL CON $129.68 01/01/80 00 10/01/06

L6677 UE TRIPLE CONTROL HARNESS $233.54 07/01/06 00 10/01/06

L6680 TEST SOCK WRIST DISART/BEL E $248.09 01/01/80 00 10/01/06

L6682 TEST SOCK ELBW DISART/ABOVE $247.03 01/01/80 00 10/01/06

L6684 TEST SOCKET SHLDR DISART/THO $372.73 01/01/80 01 01/01/86

L6686 SUCTION SOCKET $631.27 01/01/80 01 01/01/88

L6687 FRAME TYP SOCKET BEL ELBOW/W $467.87 01/01/80 01 01/01/88

L6688 FRAME TYP SOCK ABOVE ELB/DIS $506.84 01/01/80 01 01/01/88

L6689 FRAME TYP SOCKET SHOULDER DI $577.97 01/01/80 01 01/01/88


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L6690 FRAME TYP SOCK INTERSCAP-THO $669.54 01/01/80 01 01/01/88

L6691 REMOVABLE INSERT EACH $368.41 01/01/80 01 01/01/88

L6692 SILICONE GEL INSERT OR EQUAL $597.98 01/01/80 01 01/01/89

L6693 LOCKINGELBOW FOREARM CNTRBAL $2,235.13 01/01/80 01 01/01/99

L6694 ELBOW SOCKET INS USE W/LOCK $628.41 07/01/06 01 01/01/05

L6695 ELBOW SOCKET INS USE W/O LCK $523.67 07/01/06 01 01/01/05

L6696 CUS ELBO SKT IN FOR CON/ATYP $1,035.59 07/01/06 01 01/01/05

L6697 CUS ELBO SKT IN NOT CON/ATYP $1,035.59 07/01/06 01 01/01/05

L6698 BELOW/ABOVE ELBOW LOCK MECH $531.87 07/01/06 01 01/01/05

L6703 TERM DEV PASSIVE HAND MITT $300.62 01/01/07 01 01/01/07

L6704 TERM DEV SPORT/REC/WORK ATT $653.14 01/01/07 01 01/01/07

L6706 TERM DEV MECH HOOK VOL OPEN $360.99 01/01/07 01 01/01/07

L6707 TERM DEV MECH HOOK VOL CLOSE $1,378.40 01/01/07 01 01/01/07

L6708 TERM DEV MECH HAND VOL OPEN $932.88 01/01/07 01 01/01/07

L6709 TERM DEV MECH HAND VOL CLOSE $1,351.18 01/01/07 01 01/01/07

L6711 PED TERM DEV, HOOK, VOL OPEN $595.33 01/01/09 01 01/01/09

L6712 PED TERM DEV, HOOK, VOL CLOS $1,096.10 01/01/09 01 01/01/09

L6713 PED TERM DEV, HAND, VOL OPEN $1,383.40 01/01/09 01 01/01/09

L6714 PED TERM DEV, HAND, VOL CLOS $1,171.74 01/01/09 01 01/01/09

L6721 HOOK/HAND, HVY DTY, VOL OPEN $2,082.62 01/01/09 01 01/01/09

L6722 HOOK/HAND, HVY DTY, VOL CLOS $1,795.38 01/01/09 01 01/01/09

L6805 TERM DEV MODIFIER WRIST UNIT $339.57 01/01/80 01 01/01/85

L6810 TERM DEV PRECISION PINCH DEV $174.55 01/01/80 00 10/01/06

L6881 TERM DEV AUTO GRASP FEATURE $3,218.65 01/01/80 01 01/01/02

L6882 MICROPROCESSOR CONTROL UPLMB $2,441.49 01/01/80 01 01/01/02

L6883 REPLC SOCKT BELOW E/W DISA $1,378.59 07/01/06 01 01/01/06

L6884 REPLC SOCKT ABOVE ELBOW DISA $2,387.21 07/01/06 01 01/01/06

L6885 REPLC SOCKT SHLDR DIS/INTERC $3,405.88 07/01/06 01 01/01/06

L6890 PREFAB GLOVE FOR TERM DEVICE $181.87 01/01/80 00 10/01/06

L6895 CUSTOM GLOVE FOR TERM DEVICE $447.81 01/01/80 01 01/01/86

L6900 HAND RESTORAT THUMB/1 FINGER $1,608.83 01/01/80 01 01/01/82

L6905 HAND RESTORATION MULTIPLE FI $1,569.94 01/01/80 01 01/01/86

L6910 HAND RESTORATION NO FINGERS $1,529.45 01/01/80 01 01/01/82

L6915 HAND RESTORATION REPLACMNT G $647.52 01/01/80 01 01/01/82

L7360 SIX VOLT BAT OTTO BOCK/EQ EA $194.82 01/01/80 00 10/01/06

L7360 SIX VOLT BAT OTTO BOCK/EQ EA $194.82 01/01/80 01 01/01/88

L7362 BATTERY CHRGR SIX VOLT OTTO $207.03 01/01/80 00 10/01/06

L7362 BATTERY CHRGR SIX VOLT OTTO $207.03 01/01/80 01 01/01/88

L7364 TWELVE VOLT BATTERY UTAH/EQU $380.92 01/01/80 01 01/01/88

L7366 BATTERY CHRGR 12 VOLT UTAH/E $492.16 01/01/80 01 01/01/88


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L7367 REPLACEMNT LITHIUM IONBATTER $306.51 01/01/80 01 01/01/03

L7368 LITHIUM ION BATTERY CHARGER $397.34 01/01/80 01 01/01/03

L7400 ADD UE PROST BE/WD, ULTLITE $241.29 07/01/06 00 10/01/06

L7401 ADD UE PROST A/E ULTLITE MAT $270.12 07/01/06 01 01/01/06

L7402 ADD UE PROST S/D ULTLITE MAT $291.72 07/01/06 01 01/01/06

L7404 ADD UE PROST A/E ACRYLIC $437.58 07/01/06 01 01/01/06

L7405 ADD UE PROST S/D ACRYLIC $572.30 07/01/06 01 01/01/06

L7499 UPPER EXTREMITY PROSTHES NOS $0.00 01/01/85 01 01/01/85

L7500 PROSTHETIC DVC REPAIR HOURLY $32.00 01/01/80 00 10/01/06

L7510 PROSTHETIC DEVICE REPAIR REP $8.00 01/01/80 02 01/01/05 UVSP = 16

L7520 REPAIR PROSTHESIS PER 15 MIN $8.00 01/01/80 02 01/01/05 UVSP = 16

L7600 PROSTHETIC DONNING SLEEVE $0.00 01/01/06 01 01/01/06

L8000 MASTECTOMY BRA $39.04 01/01/80 00 01/01/86

L8001 BREAST PROSTHESIS BRA & FORM $98.74 01/01/80 00 10/01/06

L8002 BRST PRSTH BRA & BILAT FORM $129.88 01/01/80 00 10/01/06

L8010 MASTECTOMY SLEEVE $35.18 07/01/06 00 10/01/06

L8015 EXT BREASTPROSTHESIS GARMENT $47.19 09/01/03 00 10/01/06

L8020 MASTECTOMY FORM $167.64 01/01/80 00 10/01/06

L8030 BREAST PROSTHESIS SILICONE/E $306.28 01/01/80 01 01/01/89

L8035 CUSTOM BREAST PROSTHESIS $2,884.35 01/01/80 01 01/01/99

L8039 BREAST PROSTHESIS NOS $0.00 01/01/80 01 01/01/98

L8300 TRUSS SINGLE W/ STANDARD PAD $90.20 01/01/80 00 10/01/06

L8310 TRUSS DOUBLE W/ STANDARD PAD $142.41 01/01/80 00 10/01/06

L8320 TRUSS ADDITION TO STD PAD WA $57.16 01/01/80 00 10/01/06

L8330 TRUSS ADD TO STD PAD SCROTAL $52.79 01/01/80 00 10/01/06

L8400 SHEATH BELOW KNEE $16.83 01/01/80 00 10/01/06

L8410 SHEATH ABOVE KNEE $21.72 01/01/80 00 01/01/82

L8415 SHEATH UPPER LIMB $19.20 01/01/80 00 10/01/06

L8417 PROS SHEATH/SOCK W GEL CUSHN $59.20 01/01/80 00 10/01/06

L8420 PROSTHETIC SOCK MULTI PLY BK $20.80 01/01/80 00 10/01/06

L8430 PROSTHETIC SOCK MULTI PLY AK $22.32 01/01/80 00 01/01/82

L8435 PROS SOCK MULTI PLY UPPER LM $20.72 01/01/80 00 10/01/06

L8440 SHRINKER BELOW KNEE $44.72 01/01/80 00 10/01/06

L8465 SHRINKER UPPER LIMB $39.12 01/01/80 00 10/01/06

L8470 PROS SOCK SINGLE PLY BK $7.14 01/01/80 00 10/01/06

L8480 PROS SOCK SINGLE PLY AK $8.51 01/01/80 00 10/01/06

L8485 PROS SOCK SINGLE PLY UPPER L $11.53 01/01/80 00 10/01/06

L8499 UNLISTED MISC PROSTHETIC SER $0.00 01/01/80 01 01/01/82

L8501 TRACHEOSTOMY SPEAKING VALVE $96.88 01/01/80 00 10/01/06 6 units / 12 MO

L8615 COCH IMPLANT HEADSET REPLACE $370.34 01/01/06 1 yr + 02 01/01/06


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

L8616 COCH IMPLANT MICROPHONE REPL $86.26 01/01/06 1 yr + 02 01/01/06

L8617 COCH IMPLANT TRANS COIL REPL $75.34 01/01/06 1 yr + 02 01/01/06

L8618 COCH IMPLANT TRAN CABLE REPL $21.53 01/01/06 1 yr + 02 01/01/06

L8619 REPLACE COCHLEAR PROCESSOR $6,791.15 01/01/80 01 05/23/07

L8621 REPL ZINC AIR BATTERY $0.51 11/01/07 00 11/01/07

L8622 REPL ALKALINE BATTERY $0.27 11/01/07 00 11/01/07

L8623 LITH ION BATT CID,NON-EARLVL $50.93 01/01/06 00 01/01/06

L8624 LITH ION BATT CID, EAR LEVEL $126.96 01/01/06 00 01/01/06

L8690 AUD OSSEO DEV INT/EXT COMP $3,748.14 01/01/07 5 yrs + 01 01/01/07

L8691 AUD OSSEO DEV EXT SND PROCES $2,100.96 01/01/07 5 yrs + 01 01/01/07

L9900 O&P SUPPLY/ACCESSORY/SERVICE $0.00 01/01/80 01 01/01/00

S9349 HIT TOCOLYSIS DIEM $240.00 01/01/80 01 01/01/02

S9364 HIT TPN TOTAL DIEM $298.00 01/01/80 01 01/01/02

S9365 HIT TPN 1 LITER DIEM $298.00 01/01/80 01 01/01/02



S9368 HIT TPN OVER 3L DIEM $325.00 01/01/80 01 01/01/02

S9435 MEDICAL FOODS FOR INBORN ERR $0.00 11/01/05 0 - 20 yrs 01 11/01/05

T4521 ADULT SIZE BRIEF/DIAPER SM $0.56 01/01/07 02 01/01/05 300 units / rolling MO

T4522 ADULT SIZE BRIEF/DIAPER MED $0.60 01/01/05 02 01/01/05 300 units / rolling MO

T4523 ADULT SIZE BRIEF/DIAPER LG $0.81 01/01/07 02 01/01/05 300 units / rolling MO

T4524 ADULT SIZE BRIEF/DIAPER XL $0.97 01/01/07 02 01/01/05 300 units / rolling MO

T4525 ADULT SIZE PULL-ON SM $0.84 01/01/07 02 01/01/05 300 units / rolling MO

T4526 ADULT SIZE PULL-ON MED $0.84 01/01/07 02 01/01/05 300 units / rolling MO

T4527 ADULT SIZE PULL-ON LG $0.88 01/01/07 02 01/01/05 300 units / rolling MO

T4528 ADULT SIZE PULL-ON XL $1.01 01/01/07 02 01/01/05 300 units / rolling MO

T4529 PED SIZE BRIEF/DIAPER SM/MED $0.43 01/01/05 0 - 2 yrs 01 01/01/05 300 units / rolling MO

T4529 PED SIZE BRIEF/DIAPER SM/MED $0.43 01/01/05 3 yrs + 02 01/01/05 300 units / rolling MO

T4530 PED SIZE BRIEF/DIAPER LG $0.47 01/01/05 0 - 2 yrs 01 01/01/05 300 units / rolling MO

T4530 PED SIZE BRIEF/DIAPER LG $0.47 01/01/05 3 yrs + 02 01/01/05 300 units / rolling MO

T4531 PED SIZE PULL-ON SM/MED $0.54 01/01/07 0 - 2 yrs 01 01/01/05 300 units / rolling MO

T4531 PED SIZE PULL-ON SM/MED $0.54 01/01/07 3 yrs + 02 01/01/05 300 units / rolling MO

T4532 PED SIZE PULL-ON LG $0.54 01/01/07 0 - 2 yrs 01 01/01/05 300 units / rolling MO

T4532 PED SIZE PULL-ON LG $0.54 01/01/07 3 yrs + 02 01/01/05 300 units / rolling MO

T4533 YOUTH SIZE BRIEF/DIAPER $0.56 01/01/07 0 - 2 yrs 01 01/01/05 300 units / rolling MO

T4533 YOUTH SIZE BRIEF/DIAPER $0.56 01/01/07 3 yrs + 02 01/01/05 300 units / rolling MO

T4534 YOUTH SIZE PULL-ON $0.80 01/01/07 0 - 2 yrs 01 01/01/05 300 units / rolling MO

T4534 YOUTH SIZE PULL-ON $0.80 01/01/07 3 yrs + 02 01/01/05 300 units / rolling MO


HCPCS

Code

Short Description


descriptions)


DateAge Criteria

PA

Requirement

Type

00 = no PA

01 = PA always

02 = PA to

exceed limit or

per policy

PA Type

Begin DateLimits

T4535 DISPOSABLE LINER/SHIELD/PAD $0.37 01/01/07 02 01/01/05 300 units / rolling MO

T4541 LARGE DISPOSABLE UNDERPAD $0.41 01/01/07 0 - 2 yrs 01 01/01/05 300 units / rolling MO

T4541 LARGE DISPOSABLE UNDERPAD $0.41 01/01/07 3 yrs + 02 01/01/05 300 units / rolling MO

T4542 SMALL DISPOSABLE UNDERPAD $0.41 01/01/07 0 - 2 yrs 01 01/01/05 300 units / rolling MO

T4542 SMALL DISPOSABLE UNDERPAD $0.41 01/01/07 3 yrs + 02 01/01/05 300 units / rolling MO

T4543 DISP BARIATRIC BRIEF/DIAPER $1.96 01/03/07 00 01/01/07 300 units / rolling MO

V5266 BATTERY FOR HEARING DEVICE $6.00 10/01/03 00 01/01/02 2 units / 30 days

the information contained in the schedule is made ... · a4221 maint drug infus cath per wk $22.26...

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