DURABLE MEDICAL EQUIPMENT

Transcription

1 DURABLE MEDICAL EQUIPMENT TABLE OF CONTENTS. OVERVIEW REQUESTING PRIOR APPROVAL Durable Medical Equipment That..... Requires Prior Approval That..... Do.... Not.... Require Prior Approval How..... To... Submit a.. Prior..... Approval Request What To... Include in.. the.... Prior Approval Request Prior..... Approval Issuance After Hours Prior Approval DISCHARGE PLANNING RECORD KEEPING AND CLAIMS SUBMISSION DIABETIC SUPPLIES Diabetic Medications Blood Glucose Meters and.... Testing Supplies MEDICAL AND SURGICAL SUPPLIES EmblemHealth Medicaid Members Child Health Plus..... Members All... Other Members Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

2 This chapter includes our policies for the prescription of durable medical equipment to our members. OVERVIEW Durable medical equipment (DME) coverage is subject to the Member s benefit plan and may require prior approval from EmblemHealth's Care Management team before any service can be rendered or equipment supplied. Members may be subject to a copay/coinsurance and/or deductible. The DME vendor will notify the member when copays and/or deductibles are due. Note: EmblemHealth managing entity providers (i.e., HealthCare Partners, Montefiore, etc.) should contact their managing entity to verify coverage and procedures. REQUESTING PRIOR APPROVAL Prior approval is required for all custom and rental DME with the exception of canes, crutches and walkers for all HIP-underwritten Networks and Benefit Plans and GHI-Underwritten Medicare Benefit Plans (Medicare Choice PPO Network). Exception: GHI-underwritten Benefit Plans associated with the CBP Network, National Network, Tristate Network and Network Access Network do not require prior approval for rental DME. The network provider is responsible for requesting prior approval and, when necessary, completing the applicable Certificate of Medical Necessity form(s). Exception: Vytra network-based plans allow either the provider or the DME vendor to obtain the DME prior approval. DME must be ordered from a contracted DME vendor. Most DME vendors will work with your office to complete the prior approval request (including the applicable forms). To locate an appropriate DME provider in your area, please use our Find a Doctor search at After inputting the member's ZIP code and clicking on the member's benefit plan, select "Hospital, Facility or Urgent Care Center" and choose "Durable Medical Equipment" from the "Other Facilities" drop-down menu. Durable Medical Equipment That Requires Prior Approval Starting on January 1, 2018, the durable medical equipment listed below will require prior approval. The equipment is separated into two categories. Seven new codes are in the E category durable medical equipment and 106 new codes are in the L category orthotic and prosthetic procedure, devices. The prior approval requirement applies to all EmblemHealth members. Code E0185 E0482 Gel or gel-like pressure pad for mattress, standard mattress length and width Cough stimulating device, alternating positive and negative airway pressure Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

3 E0618 E0619 E0630 E0720 E0730 L0458 L0460 L0462 L0464 L0466 L0468 L0470 L0472 L0480 L0482 Apnea monitor, without recording feature Apnea monitor, with recording feature Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) Transcutaneous electrical nerve stimulation (tens) device, two lead, localized stimulation Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation Tlso, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, pre, includes fitting and Tlso, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Tlso, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, pre, includes fitting and Tlso, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, pre, includes fitting and Tlso, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Tlso, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Tlso, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, pre, includes fitting and Tlso, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, pre, includes fitting and Tlso, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

4 L0484 L0486 L0488 L0490 L0491 L0492 L0625 L0626 L0627 L0628 L0629 L0630 trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom Tlso, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom Tlso, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, pre, includes fitting and Tlso, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the t-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, pre, includes fitting and Tlso, sagittal-coronal control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, pre, includes fitting and Tlso, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, pre, includes fitting and Lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, pre, off-the-shelf Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, pre, off-the-shelf Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

5 L0631 L0632 L0633 L0634 L0635 L0636 L0637 L0638 L0639 L0640 L1005 L1200 L1300 L1310 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, pre, includes fitting and Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom Tension based scoliosis orthosis and accessory pads, includes fitting and Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis only Other scoliosis procedure, body jacket molded to patient model Other scoliosis procedure, post-operative body jacket Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

6 L1820 L1830 L1831 L1832 L1834 L1836 L1843 L1845 L1847 L1850 L1900 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980 L2000 L2005 L2010 L2020 Knee orthosis, elastic with condylar pads and joints, with or without patellar control, pre, includes fitting and Knee orthosis, immobilizer, canvas longitudinal, pre, off-the-shelf Knee orthosis, locking knee joint(s), positional orthosis, pre, includes fitting and Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee orthosis, without knee joint, rigid, custom Knee orthosis, rigid, without joint(s), includes soft interface material, pre, off-the-shelf Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus a Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee orthosis, swedish type, pre, off-the-shelf Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom Ankle orthosis, ankle gauntlet or similar, with or without joints, pre, off-the-shelf Ankle orthosis, ankle gauntlet or similar, with or without joints, custom Ankle foot orthosis, multiligamentous ankle support, pre, off-the-shelf Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, pre, includes fitting and Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom Ankle foot orthosis, plastic or other material, pre, includes fitting and Afo, rigid anterior tibial section, total carbon fiber or equal material, pre, includes fitting and Ankle foot orthosis, plastic or other material, custom Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, pre, includes fitting and Ankle foot orthosis, posterior solid ankle, plastic, custom Ankle foot orthosis, plastic with ankle joint, custom Ankle foot orthosis, plastic or other material with ankle joint, pre, includes fitting and Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), custom Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), without knee joint, custom Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'ak' orthosis), custom Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

7 L2030 L2034 L2035 L2036 L2037 L2038 L2040 L2050 L2060 L2070 L2080 L2090 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 L2134 L2136 L3002 L3765 L3766 L4396 L5510 Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'ak' orthosis), without knee joint, custom Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle, pre, includes fitting and Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom Hip knee ankle foot orthosis, torsion control, bilateral rotation straps, pelvic band/belt, custom Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom Hip knee ankle foot orthosis, torsion control, unilateral rotation straps, pelvic band/belt, custom Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/ belt, custom Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft, pre, includes fitting and Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, pre, includes fitting and Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, pre, includes fitting and Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom Kafo, fracture orthosis, femoral fracture cast orthosis, soft, pre, includes fitting and Kafo, fracture orthosis, femoral fracture cast orthosis, semi-rigid, pre, includes fitting and Kafo, fracture orthosis, femoral fracture cast orthosis, rigid, pre, includes fitting and Foot, insert, removable, molded to patient model, plastazote or equal, each Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom, includes fitting and Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom, includes fitting and Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, pre item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

8 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5673 Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model Preparatory, below knee 'ptb' type socket, non-alignable system, no cover, sach foot, pre, adjustable open end socket Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model Preparatory, above knee- knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, pre adjustable open end socket Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon no cover, sach foot, laminated socket, molded to model Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, laminated socket, molded to patient model Addition to lower extremity, below knee/above knee, custom from existing mold or pre, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism 2015 That Do Not Require Prior Approval Healthcare Common Procedure Coding System () Level II is a standardized coding system used primarily to identify products, supplies and services not included in the CPT codes, such as durable medical equipment, prosthetics, orthotics and supplies when used outside a physician s office. The table below lists the codes that do not require prior approval for any benefit plans associated with the following networks: Associated Dual Assurance Network Enhanced Care Prime Network EmblemHealth Dual Assurance Network Premium Network Prime Network Medicare Choice PPO Network Medicare Essential Network NY Metro Network Select Care Network VIP Prime Network Vytra Network Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

9 A4561 A4562 A4565 A4624 A4629 A6258 A6402 A6531 A6532 A7003 A7005 A7007 A7010 A7013 A7015 A7032 A7034 A7035 A7036 A7037 A7038 A7039 A7046 A7520 E0100 E0110 E0114 E0130 E0135 E0143 E0147 E0148 E0149 E0153 E0154 E0155 E CODES THAT DO NOT REQUIRE PRIOR APPROVAL Pessary, rubber, any type Pessary, nonrubber, any type Slings Tracheal suction catheter, any type than closed system, each Tracheostomy care kit Transparent film > 16 <= 48 inches Sterile gauze <= 16 square inches Compression Stockings, below the knee, mg Hg each Compression Stockings, below the knee, mg Hg each Administration set, with small volume nonfiltered pneumatic nebulilzer, disposable Nondisposable nebulizer set Large-volume nebulizer, disposable Disposable corrugated tubing Disposable compressor filter Aerosol mask, used with nebulizer Replacement nasal cushion Nasal application device Positive airway pressure headgear Positive airway pressure chinstrap Positive airway pressure tubing Positive airway pressure filter Filter, nondisposable with PAP Water chamber for humidifier, used with positive airway pressure device, replacement, each Tracheostomy/laryngectomy tube, non-cuffed poluvinylchloride (PVC), silicone or equal, each Cane, inc. canes of all materials, adjustable Crutch, forearm, pair Crutch, underarm, pari, no wood Walker, rigid adjustable or fixed height Walker, folding, adjustable or fixed height Walker, folding, wheeled, adjustable or fixed height Walker, heavy-duty, multiple braking system, variable wheel resistance Heavy-duty walker, no wheels Heavy-duty walker, wheeled Forearm crutch, platform attachment Walker, platform attachment Walker, wheel attachment, pair Walker, seat attachment E0158 Walker, leg extenders, (set of 4) E0163 E0165 E0167 DURABLE MEDICAL EQUIPMENT Commode chair with fixed arms Commode chair with detached arms Commode chair, pail or pan Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

10 2015 CODES THAT DO NOT REQUIRE PRIOR APPROVAL E0168 E0188 E1081 E0185 E0199 E0202 E0482 E0500 E0570 E0560 E0565 E0600 E0602 E0603 E0604 E0618 E0619 E0621 E0630 E0705 E0720 E0730 E0731 E0830 E0840 E0849 E0850 E0855 E0856 E0860 E0870 E0880 E0890 E0900 E0910 E0911 E0912 Commode chair, extra wide &/or heavy-duty, stationary or mobile, with or without arms, any type, each Synthetic sheepskin pad APP (alternating pressure pad) mattress/overlay, powered, Group I Gel-like pressure pad for mattress, Group I Dry pressure pad for mattress Phototherapy (bilirubin) light with photometer Cough stimulating device, alternating positive & negative airway pressure IPPB machines, all types Nebulizer, with compressor Humidifier, durable, for supplemental humidification Compression, air, power source Respiratory suction pump, home model, portable or stationary, electric Breast pumps, manual Breast pumps, electric Breast pumps, hospital grade Apnea monitor without recording feature Apnea monitor with recording feature Patient lift, sling or seat Hoyer lift Transfer board or device, any type, each Tens unit, 2 leads, localized Transcutaneous electrical nerve stimulation device Form fitting conductive garment for delivery of Tens unit Ambulatory traction devices, all types Traction frame for headboard, cervical traction Traction equipment, freest&ing frame, pneumatic, cervical Traction st&, freest&ing, cervical Cervical traction equipment not requiring additional st& or frame Cervical traction device, cervical collar with inflatable bladder Traction equipment, over door, cervical Traction, freest&ing, extremity (e.g. Bucks) Traction, freest&ing, extremity (e.g. Bucks) Traction frame attached to footboard, pelvic Traction st& freest&ing, pelvic Trapeze bars, aka Patient Helper, attached to bed, with grab bar Trapeze bar attached to bed with grab bar, weight greater than 250 lbs. Trapeze bar, heavy duty with grab bar, weight greater than 250 lbs., freest&ing Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

11 2015 CODES THAT DO NOT REQUIRE PRIOR APPROVAL E0958 E0966 E0968 E0971 E1020 E1031 E1035 E1037 E1038 E1039 E1354 E2601 E2602 E2603 E2604 E2605 E2606 E2607 E2608 K0669 K0734 K0735 K0736 K0737 L0112 L0120 L0130 L0140 L0150 L0160 Manual wheelchair accessory, one-arm drive attachment, each Manual wheelchair accessory, headrest extension, each Commode seat, wheelchair Manual wheelchair accessory, anti-tipping device, each Residual limb support system for wheelchair Rollabout chair, any & all types, with castors Multi-position transfer system Transport chair, pediatric size Transport chair, adult size Transport chair, adult size, heavy duty, weight greater than 300 lbs. Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only General use wheelchair seat cushion, width less than 22 in., any depth General use wheelchair seat cushion, width 22 in. or greater, any depth Skin protection wheelchair seat cushion, width less than 22 in., any depth Skin protection wheelchair seat cushion, width 22 in. or greater, any depth Positioning wheelchair seat cushion, width less than 22 in., any depth Positioning wheelchair seat cushion, width 22 in. or greater, any depth Skin protection & positioning wheelchair seat cushion, width less than 22 in., any depth Skin protection & positioning wheelchair seat cushion, width 22 in. or greater, any depth Wheelchair accessory, wheelchair seat or back cushion Skin protection wheelchair seat cushion, adjustable, width less than 22 in., any depth Skin protection wheelchair seat cushion, adjustable, width 22 in. or greater, any depth Skin protection & positioning wheelchair seat cushion, adjustable, width less than 22in., any depth Skin protection & positioning wheelchair seat cushion, adjustable, width 22 in. or greater, any depth Cranial-cervical orthotic Cervical, flexible, nonadjustable (foam collar) Cervical, flexible, thermoplastic collar, moded to patient Cervical, semi-rigid, adjustable, plastic collar Cervical, semi-rigid, adjustable, molded chin cup (plastic collar with m&ibular/occipital piece) Cervical, semi-rigid, wire frame occipital/m&ibular support Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

12 2015 CODES THAT DO NOT REQUIRE PRIOR APPROVAL L0170 L0172 L0174 L0180 L0190 L0200 L0220 L0430 L0450 L0452 L0454 L0456 L0458 L0460 Cervical, moded to patient Cervical, semi-rigid, thermoplastic foam, two-piece Cervical, simi-rigid, thermoplastic foam, two-piece with thoracic extenstion Cervical, multiple-post collar, occipital/m&ibular supports, adjustable Cervical, multiple post collar, occipital/m&ibular supports, adjustable cervical bars Cervical, multiple post collar, occipital/m&ibular supports, adjustable cervical bars, thoracic extension Thoracic, rib belt, custom- Dewall Posture Protector Thoracis-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), inc. shoulder straps & closures, pre, inc. fitting & Throacic-lumbar-sacral orthotic (TLSO), flexible, custom- Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), inc. shoulder straps & closures, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel & soft anterior apron, extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, inc. straps & closures, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferiror to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inlcudes straps & closures, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferiror to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, pre, inc. fitting & Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

13 2015 CODES THAT DO NOT REQUIRE PRIOR APPROVAL L0462 L0464 L0466 L0468 L0470 L0472 L0480 Thoracic-lumbar-sacral orthotic (TLSO), 3 rigid platic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis ot the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), 4 rigid plastic shells, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal & transverse planes, lateral strength is provided by overlapping plastic & stabilizing closure, inc. straps & closures, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), sagittal control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, inc. fitting & shaping the frame, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, extends from the sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic & lateral frame pieces, restricts gross trunk motion in sagittal & coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, inc. fitting & shaping the frame, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame, flexible soft anterior apron with straps, closures & padding, extends from the sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic & lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal & transverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, inc. fitting & shaping the frame, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior & lateral frame extends from symphysis pubis to sternal notch with 2 anterior componenets (one public & one sternal), posterior & lateral pads with straps & closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal & transverse planes, inc. fitting & shaping the frame, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), rigid plastic, custom- Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

14 2015 CODES THAT DO NOT REQUIRE PRIOR APPROVAL L0482 L0484 L0486 L0488 L0490 L0491 L0492 L0621 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control Thoracic-lumbar-sacral orthotic (TLSO), rigid plastic, custom- Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal & transverse planes, inc. a carved plaster or CAD-CAM model, custom Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal & transverse planes, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, 1 piece rigid plastic shell with overlapping reinforced anterior, multiple straps & closures, posterior extends from sacrococcygeal junction & terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal & coronal planes, pre, inc. fitting & Thoracic-lumbar-sacral orthotic (TLSO), sagittalcoronal control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures, pre, inc. fitting & TLSO, sagittal-coronal control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction & terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal & coronal planes, lateral strength is provided by overlapping plastic & stabilizing closures, inc. straps & closures,pre, inc. fitting & Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion about the sacroillac joint, inc. straps & closures, may inc. pendulous abdomen design, pre, inc. fitting & Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

15 2015 CODES THAT DO NOT REQUIRE PRIOR APPROVAL L0622 L0623 L0625 L0626 L0627 L0628 L0629 L0630 L0631 L0632 L0633 Sacroiliac orthotic (SIO), flexible pelvisacral, custom Sacroiliac orthotic, provides pelvic-sacral support, with rigid or semirigid panels over the sacrum & abdomen, reduces motion about the sacroillac joint, inc. straps & closures, may inc. pendulous abdomen design, pre, inc. fitting & Lumbar orthotic, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps, closures, may inc. pendulous abdomen design, shoulder straps, stays, pre, inc. fitting & Lumbar orthotic, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intevertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, pre, inc. fitting & Lumbar orthotic, sagittal control, with rigid posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, shoulder straps, pendulous abdomen design, pre, inc. fitting & Lumbar-sacral orthotic (LSO), flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. stays, shoulder straps, pendulous abdomen design, pre, inc. fitting & Lumbar-sacral orthotic (LSO), flexible, provides lumbar-sacral support, posterior Lumbar-sacral orthotic (LSO), sagittal control, rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, pre, inc. fitting & Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior & posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, pre, inc. fitting & Lumbar-sacral orthotic (LSO), sagittal, rigid frame, custom- Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

16 2015 CODES THAT DO NOT REQUIRE PRIOR APPROVAL L0634 L0635 L0636 L0637 L0638 L0639 L0640 L0700 L0710 L0810 L0820 L0830 L0859 L0861 L0970 lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, pre, inc. fitting & Lumbar-sacral orthotic (LSO), flexion control, custom Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral fame/ panel(s), produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, anterior panel, pendulous abdomen design, pre, inc. fitting & Lumbar-sacral orthotic (LSO), sagittal, rigid panel, custom- Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid anterior & posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, inc. straps & closures, may inc. padding, stays, shoulder straps, pendulous abdomen design, pre, inc. fitting & Lumbar-sacral orthotic (LSO), sagittal-coronal panel, custom- Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/ panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material & stabilizing closures, inc. straps & closures, may inc. soft interface, pendulous abdomen design, pre, inc. fitting & Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid shell(s) Cervical-thoracic-lumbar-sacral orthotic (CTLSO), A-P-L control, molded Cervical-thoracic-lumbar-sacral orthotic (CTLSO), A-P-L control, with interface material Halo, cervical, incorporated into jacket vest Halo, cervical, incorporated into body jacket Halo, cervical, incorporated into Milwaukee type Addition to halo procedure, magnetic resonance image compatible systems, rings & pins, any material Addition to halo procedure, replacement liner/interface material TLSO, corset front Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/

17 2015 CODES THAT DO NOT REQUIRE PRIOR APPROVAL L0972 L0974 L0976 L0984 L1000 L1001 L1005 L1010 L1020 L1025 L1030 L1040 L1050 L1060 L1070 L1080 L1085 L1090 L1100 L1110 L1120 L1200 L1210 L1220 L1230 L1240 LSO, corset front TLSO, full corset LSO, full corset Protective body sock, each Cervical-thoracic-lumbar-sacral orthotic (CTLSO), Milwaukee, initial model Cervical-thoracic-lumbar-sacral orthotic (CTLSO) immobilizer, infant size, pre, inc. fitting & Tension based scoliosis orthotic & accessory pads, inc. fitting & Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, axilla sling Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, kyphosis pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, kyphosis pad floating Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar bolster pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar or lumbar rib pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, sternal pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, thoracic pad Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, trapezius sling Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, outrigger Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, outrigger, bilateral with vertical extensions Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, lumbar sling Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring flange, plastic or leather Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, ring flange, plastic or leather, molded to patient model Addition to cervical-thoracic-lumbar-sacral orthotic (CTLSO) or scoliosis orthotic, cover for upright, each Thoracic-lumbar-sacral-orthotic (TLSO), inclusive Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lateral thoracic extension Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), anterior thoracic extension Addition to Thoracic-lumbar-sacral orthotic (TLSO)(low profile), Milwaukee type superstructure Addition to Thoracic-lumbar-sacral orthotic (TLSO) (low profile), lumbar derotation pad Back to Table of Contents EmblemHealth Provider Manual Last Updated: 11/30/