Appendix J - High Cost DME <21
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1 Appendix J - High Cost DME <21 Auth required Y or N Description Notes CPT/ HCPCS Codes Mod Service Limits Durable Medical Equipment <21 Service limits indicated on fee schedule may be exceeded for this age group/temporary wheelchair rentals may be exceeded for all age groups with medical necessity Safety Enclosure Frame/Canopy for use w/hospital Bed, any type E per 5 years
2 Wheelchair Accessory, ventilator tray, gimbaled E per 4 years Wheelchair, pediatric sized, tiltin space, rigid, adjustable, w/seating system E per 5 years Wheelchair, pediatric sized, tiltin space, folding, adjustable, w/seating system E per 5 years Wheelchair, pediatric sized, tiltin space, rigid, adjustable, without seating system E per 5 years
3 Wheelchair, pediatric sized, tiltin, folding, adjustable, without seating system E per 5 years Wheelchair, pediatric sized, rigid, adjustable, w/seating system E per 5 years Wheelchair pediatric sized, folding, adjustable, w/seating system E per 5 years Wheelchair pediatric sized, rigid, adjustable, w/o seating system E per 5 years Wheelchair, pediatric sized, folding, adjustable, w/o seating system E per 5 years
4 Equipment & Services Greater than $500 but not identified as on Fee Schedule Nasogastric Tubing w/stylet B per year Nasogastric Tubing w/o stylet B per year Enteral Formula, manufactured, blenderized, adminstered thru enteral feeding B per month Enteral formula, pediatrics, nutritionally complete, administered thru enteral feeding tube B per month Enteral formula, pediatrics, nutritionally complete, administered orally B4160 SC 930 per month
5 Enteral formula, pediatrics, hydrolyzed/amino acids, administered thru feeding tube B per month Enteral formula, pediatrics, hydrolyzed/amino acids, administered orally B4161 SC 930 per month Enteral formula, pediatrics, special metabolic needs for inherited disease of metabolism, administered thru enteral feeding tube B per month
6 Enteral formula, pediatrics, special metabolic needs for inherited disease of metabolism, administered orally B4162 SC 930 per month Enteral nutrition infusion pump, without alarm Rental Only B9000 Enteral nutrition infusion pump, with alarm Rental Only B9002 Parenteral nutrition infusion pump, w/alarm Rental Only B9004 NOC for enteral supplies B per year Phototherapy (Bilirubin) light w/photometer Rental Only E per medical event up to 5 days
7 Hospital bed, semielectric, w/mattress and any type side rails E per 8 years Hospital bed, total electric, w/mattress, any type side rails E per 8 years Oximeter device for measuring blood oxygen levels Rental Only E0445 Apnea monitor w/o recording feature Rental Only E0618 Apnea monitor w/recording feature Rental Only E0619 Pneumatic compressor, segmental home model w/o calibrated gradient pressure E per 8 years
8 Pneumatic compressor, segmental home model with calibrated gradient pressure E per 8 years Neuromuscular Stimulator for scoliosis E0744 Neuromuscular Stimulator electronic shock system E0745 Ambulatory Infusion pump, mechanical, resuable, for infusion 8 hrs or greater Rental Only E0779 Ambulatory Infusion pump, mechanical, resuable, for infusion less than 8 hrs Rental Only E0780
9 Ambulatory infusion pump, single/multiple channels, worn by patient Rental Only E0781 Parenteral infusion pump, stationary, single/multi channel Rental Only E0791 Passive motion exercise device Rental Only E days per medical event INFUSION SUPPLIES FOR EXTERNAL DRUG INFUSION PUMP, PER CASSETTE OR BAG (LIST DRUGS SERATELY) BR (by report), A4222 UP TO 365 PER YEAR MAX
10 ENTERAL FORMULA, FOR PEDIATRICS, HYDROLYZED/AMI NO ACIDS AND PEPTIDE CHAIN PROTEINS, INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT BR (by report) B4161
11 ENTERAL FORMULA, FOR PEDIATRICS, HYDROLYZED/AMI NO ACIDS AND PEPTIDE CHAIN PROTEINS, INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED ORALLY, 100 CALORIES = 1 UNIT BR (by report) B4161 SC
12 ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERIETED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT BR (by report) B4162
13 ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERIETED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED ORALLY, 100 CALORIES = 1 UNIT BR (by report) SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE E0316
14 OXIMETER DEVICE FOR MEASURING BLOOD OXYGEN LEVELS, NON- INVASIVE E0445 RO (Rental Only) APNEA MONITOR, WITHOUT RECORDING FEATURE E0618 RO (Rental Only) APNEA MONITOR, WITH RECORDING FEATURE E0619 RO (Rental Only) NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS E0744 NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT E0745
15 AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION 8 HOURS OR GREATER E0779 RO (Rental Only) AMBULATORY INFUSION PUMP, MECHANICAL, REUSABLE, FOR INFUSION LESS THAN 8 HOURS E0780 RO (Rental Only) AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT, WORN BY TIENT E0781 RO (Rental Only)
16 RENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTI- CHANNEL E0791 RO (Rental Only) WHEELCHAIR ACCESSORY, VENTILATOR TRAY GIMBALED E1030 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SCE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM E1231 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SCE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM E1232
17 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SCE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM E1233 WHEELCHAIR, PEDIATRIC SIZE, TILT-IN-SCE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM E1234 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITH SEATING SYSTEM E1235
18 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITH SEATING SYSTEM E1236 WHEELCHAIR, PEDIATRIC SIZE, RIGID, ADJUSTABLE, WITHOUT SEATING SYSTEM E1237 WHEELCHAIR, PEDIATRIC SIZE, FOLDING, ADJUSTABLE, WITHOUT SEATING SYSTEM E1238
19 CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, RIGID, WITH SOFT INTERFACE MATERIAL, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT(S), Medical Necessity S1040
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