CurrentCalifornia Department of Health Care ServicesPolicy N/A

Durable Medical Equipment (DME): Other DME Equipment

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Governs reimbursement and provider requirements for various durable medical equipment items not in specific DME groups (e.g., infusion, oxygen, speech devices, therapeutic mattresses, wheelchairs) for Medi‑Cal recipients and providers submitting claims to California Department of Health Care Services.

Policy Summary

PayerCalifornia Department of Health Care Services

PolicyDurable Medical Equipment (DME): Other DME Equipment

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2023

Last ReviewMar 1, 2023

Next Review DateN/A

Key ActionSubmit a Treatment Authorization Request (TAR) with required prescription and clinical documentation when authorization is required for specific DME items (e.g., gait trainers, lymphedema pumps, NPWT, stairway chairlifts).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

March 2023page updated

20+item categories

No ship/handlingbilling rule

Lowest cost itemlowest cost requirement

TAR requiredTAR required

Coverage and Medical Necessity Criteria for Other DME

Other DME items (overview)

This section includes coverage and policy information for a variety of other durable medical equipment (DME) items. Providers must consult referenced Provider Manual sections for specific billing, documentation, frequency limits, and TAR requirements.

Authorization for DME is limited to the lowest cost item that meets the patient's medical needs per CCR Title 22, Section 51321(g).

The date of delivery to the recipient is the date of service for billing purposes; shipping and handling charges are not reimbursable.

This section covers multiple items including cough stimulating devices, electrodes and lead wires, Haberman feeder, NPWT devices, osteogenesis stimulators, and others; providers should refer to the specific subsections and related Provider Manual sections for item-specific rules.

Coverage criteria for walkers, gait trainers, gait modulation devices, bathroom equipment, and DME for disabled parent

Covered when ALL of the following are met:

Gait trainer is prescribed and medically necessary for the recipient.

A written prescription signed by the treating practitioner (or electronic equivalent) accompanies the TAR or claim.

Evaluation by a licensed physical therapist documents that the recipient can use the gait trainer purposefully, can partially bear weight and advance the lower extremities, has satisfactory head control, requires greater structural/balance support than a walker, and has no other form of self-initiated mobility.

Documentation addresses practical considerations: attendant assistance needs, supervision, space for safe use, caregiver compliance with a home program for pediatric recipients, and adequacy of upper-extremity weight-bearing and joint stability.

Providers bill gait trainers with HCPCS codes E8000–E8002 and submit a Treatment Authorization Request (TAR) as required.

Gait modulation devices (e.g., E3200) require an approved TAR and meet additional age, diagnosis, and modifier requirements as specified in the guidance.

Bathroom and related items

Bathroom assistive items may not be Medicare-covered; may be billed to Medi-Cal without prior Medicare denial per guidance.
Commode chairs (E0170/E0171) require TAR documentation of neuromuscular dysfunction or arthropathy and are subject to month-of-service restrictions.

DME to assist a disabled parent may be covered when TAR includes prescription and documentation of the recipient's medical disability; claims must use HCPCS A9999 with ICD-10 Z73.6 and modifier SC.

DME for a disabled parent

Covered when ALL of the following are met:

A Treatment Authorization Request (TAR) is submitted for DME provided to assist a disabled parent.

TAR includes a prescription from the treating practitioner for the specific DME item and documentation from an appropriate clinician (physician, NP, CNS, or PA) of the recipient's medical disability justifying the DME.

Claims for DME for a disabled parent must be submitted using HCPCS A9999, ICD-10-CM diagnosis code Z73.6, and modifier SC.

Reimbursement for such items follows the reimbursement policy associated with each specific DME item (purchase/rental/supply pricing) as described in the DME overview and related sections.

Hospital beds and pediatric enclosed beds — medical necessity criteria

Hospital or pediatric enclosed beds are covered when ALL applicable medical necessity criteria below are met:

The hospital bed is necessary to treat the documented medical condition and is expected to produce a positive medical outcome or prevent complications that would not occur without the bed.

The desired medical benefit cannot be attained by an ordinary bed nor by modifying an ordinary bed using commercially available items.

Pediatric enclosed bed additional criteria

Behavioral necessity is documented; behavioral interventions attempted without success; less restrictive alternatives tried and failed; an ordinary bed cannot be modified to meet needs; no other feasible alternative exists; request is not for caregiver convenience.

Fixed-height bed criteria (at least one): positioning not feasible in non-hospital bed, need to prevent contractures with history/risk, history of pain related to positioning, need to avoid respiratory infections related to positioning, need for >30° head elevation for specified conditions, or need for special attachments/traction equipment. (Minimum head elevation requirement: ≥30°.)

Variable-height bed: meets fixed-height criteria and requires height adjustment for transfers to chair/wheelchair or to standing.

Semi-electric bed: meets fixed-height criteria and requires frequent or immediate body position changes.

Heavy-duty extra-wide beds: meet fixed-height criteria and recipient weight is 351 to 600 pounds.

Extra heavy-duty beds: meet fixed-height criteria and recipient weight exceeds 600 pounds.

For CCS-managed children, requests are reviewed by CCS per Title 22 regulations.

Accessory billing restrictions

Billing restrictions and mutual exclusivity rules:

HCPCS E0271, E0272, E0305 and E0310 (mattresses and bedrails) are not reimbursable if billed with E0303, E0304, E0328 or E0329; if billed separately, payment will be limited to the allowed amount for E0303/E0304/E0328/E0329.

HCPCS E0316 (safety enclosure frame/canopy) is not separately reimbursable when billed for the same recipient with HCPCS E0300 (pediatric crib, hospital grade, fully enclosed).

Heavy-duty extra-wide hospital beds

Covered when ALL of the following are met:

The recipient meets the fixed-height hospital bed coverage criteria (see hospital bed criteria).

Recipient's weight is between 351 and 600 pounds.

Extra heavy-duty hospital beds

Covered when ALL of the following are met:

The recipient meets the fixed-height hospital bed coverage criteria (see hospital bed criteria).

Recipient's weight exceeds 600 pounds.

Hospital bed medical necessity and documentation

Documentation required to certify medical necessity:

Medical necessity must be clearly documented by the licensed practitioner; a signed prescription (or electronic equivalent) must accompany the TAR.

Clinical documentation must describe condition, severity/frequency of symptoms, expected therapeutic outcome, caregiver availability, and recipient's ability to operate the bed.

Providers must submit DHCS form 6181 Certificate of Medical Necessity for All DME (Except Wheelchairs and Scooters) or equivalent documentation containing the required information.

Standers/standing frames medical necessity

Standers/standing frames are covered when ALL of the following are met:

The device would allow increased independence in activities of daily living, provide pressure relief not achievable by other means, or increase lower body strength for eligible neuromuscular conditions.

Device is not provided for recipients with complete paralysis of hips/legs when standing would not improve or maintain range of motion or would be unsafe.

Prescribing practitioner documents training, absence of fracture risk, absence of vertigo/nausea on standing, recipient willingness and ability to stand, and availability of suitable home facilities/assistance.

TAR requirements and rental-to-purchase rule for standers

TAR requirements and rental-to-purchase rule:

TARs for standing systems (E0637, E0638, E0641, E0642) must include diagnosis, age/size, functional description (sitting/standing ability, transfers), functional goals and current programs, daily activities, relevant impairments, and history of standing/trials.

A mandatory three-month rental period is required before purchase unless the recipient has participated in a community standing program three to four times per week for at least three months.

Patient transfer systems and stairway chairlifts coverage

Patient transfer systems and stairway chairlifts coverage criteria and TAR requirements:

HCPCS E1035 and E1036 are covered subject to coding, frequency, and TAR rules; E1036 requires a TAR and has a once-in-five-years frequency limit.

HCPCS E1035 and E1036 are not separately payable within the same month as code E0240 (bath/shower chair).

Each TAR for a stairway chairlift (E1399) is reviewed case-by-case considering medical necessity, cost, less costly options, and recipient/caregiver ability to operate safely; required documentation includes residence room descriptions, practitioner's prescription, and explanation of medical necessity and alternatives tried.

Reimbursement for stairway chairlifts (E1399) is 'By Report.'

Phototherapy coverage and limits

Phototherapy light (E0202) is covered when ALL of the following are met:

Infant's total serum bilirubin is in the 'optional range' per AAP guidelines, the infant is feeding/voiding/stooling well and appears well, and close follow-up evaluation is possible.

Coverage is as a daily rental only and must be billed with modifier RR.

Frequency limit is 10 days per lifetime per infant; a TAR can override frequency limits (for example, multiple infants) with appropriate claim documentation.

Claims may be submitted under the mother's Medi‑Cal ID when the infant's Medi‑Cal eligibility is not yet established; patient relationship must be indicated on the claim.

Lymphedema pumps / pneumatic compression devices

Lymphedema pumps and pneumatic compression devices are covered when ALL of the following are met:

Recipient has confirmed primary or secondary lymphedema associated with functional impairment and one of the specified ICD-10 codes is on the TAR (I89.0, I97.2 or Q82.0; Q82.0 exclusions noted for E0658/E0659).

Conservative therapies (elevation, exercise, massage, compression bandage/garment) have been tried for at least 30 days and failed, and the recipient has demonstrated compliance with past treatments.

All listed HCPCS codes for pumps and appliances require authorization and prescription by a licensed practitioner; an initial 60-day trial rental may be authorized to establish clinical effectiveness.

Purchase or continued rental may be authorized when documented effectiveness is shown (pre- and post-treatment measurements or functional improvement).

Lymphedema pump/device coverage criteria

Clinical and prior-conservative-therapy criteria required for coverage:

Confirmed diagnosis of primary or secondary lymphedema documented in the medical record.

Lymphedema is associated with functional impairment.

At least 30 days of conservative treatments (elevation, exercise, massage, compression bandage/garment) have been tried and failed.

Recipient has demonstrated compliance with past recommended treatments.

Contraindications such as active infection or deep vein thrombosis in the affected limb preclude coverage.

Purchase or continued rental requires documentation of clinical effectiveness (pre-/post-treatment measurements or functional improvement).

Blood glucose monitors coverage and documentation

Home blood glucose monitors are covered when ALL of the following are met:

Covered diagnoses

Type I insulin-dependent diabetes.
Type II non-insulin-dependent diabetes.
Diabetes mellitus complicating pregnancy.
Gestational diabetes with intent to monitor blood glucose at home.

Monitors billed with HCPCS E0607 or E2104 (integrated cartridges); special-feature monitors billed with E2100/E2101; adjunctive alert systems billed E2102 with NU/RB modifiers where applicable.

Claims must include relevant ICD-10-CM diagnosis codes. For E0607, documentation of recipient or caregiver competency and that the device is for home use is required.

Authorization is always required for special-feature monitors (E2100/E2101); authorization for E0607 is required when cost exceeds TAR threshold limits and TAR must include required ICD-10 codes and statements justifying least-cost effective item and special features where applicable.

Integrated cartridges billed with A4271; test strips and other supplies billed per supply coding guidance in the Part 2 manual.

Blood pressure equipment billing stance

Billing stance (purchase-only rule):

HCPCS codes A4660, A4663 and A4670 are purchase-only and must be billed with modifier NU; they do not require documentation for reimbursement except pricing information and may be billed with any ICD-10-CM that justifies medical necessity.

If billed with modifier RR (rental) the claim will be denied.

Breastfeeding aids and supplies coverage and limits

Breastfeeding aids and supplies are covered when ALL of the following are met:

Breast pumps (E0602, E0603, E0604) include necessary supplies (tubing, adapter, bottle/cap, shield, locking ring) and must be the lowest-cost option that meets medical necessity.

Breast pump supplies (A4281–A4288) are purchase-only (modifier NU), reimbursed By Report, and require a statement that the patient owns a breast pump in Box 19 or as attachment; A4281–A4286 reimbursable up to two replacements per recipient per 12 months without TAR and not separately reimbursable within same month as E0602/E0603 purchase.

Disposable breast milk bags (A4287) are reimbursable when medically necessary (e.g., infant unable to latch); frequency limit 120 bags per infant without TAR; mother's Medi-Cal ID may be used initially if infant ID not yet established; claims must state pump is patient-owned.

Pasteurized donor human milk (T2101) is covered per 3-ounce unit, up to 35 ounces per day, coverage up to 12 months when medically necessary.

E0602 and E0603 require no TAR; labor charges K0739/K0740 are not separately reimbursable.

Breastfeeding supplies

Supply-specific criteria and limits:

HCPCS A4287 reimbursable when medically necessary (for example, infant unable to latch); limit 120 bags per infant without TAR; mother's Medi-Cal ID may be used initially until infant ID established; claim must state pump is patient-owned.

HCPCS T2101 covers pasteurized donor human milk from licensed facility, billed per 3-ounce unit, with a 35-ounce per day limit and coverage up to 12 months of age.

Cough device and electrode supplies

Cough device and electrode supplies coverage and billing rules:

Use HCPCS A7020 for interfaces for cough stimulating devices (replacement only); A7020 is not separately reimbursable with the rental or initial purchase of the cough device.

Claims that bill codes A7027–A7046 with E0482 will be denied; A7020 is the correct supply code for replacement interfaces.

Electrodes (A4556) and lead wires (A4557) are reimbursable for patient-owned DME items except TENS units; provider must document ownership in Box 19 or attachment.

Electronic pump enema (A4479)

A4479 (electronic transanal irrigation system) is reimbursable with TAR and limits:

An approved TAR is required for HCPCS A4479 prior to reimbursement.

Diagnosis code on the TAR is limited to specified bowel/intestinal ICD-10-CM codes (K59.00, K59.01, K59.02, K59.03, K59.04, K59.09, K91.89, R15.9).

Frequency limit: one device every two years; Modifier NU required for purchase; Modifiers RB and RA are allowable.

NPWT coverage criteria

Negative Pressure Wound Therapy (NPWT) is covered when ALL of the following criteria and documentation requirements are met:

NPWT devices and supplies must be billed with the appropriate HCPCS codes (E2402, A6550, A7000, A7001, K0743–K0746) and follow the rental/purchase limitations specified.

An initial TAR for the NPWT pump will be granted for no more than 15 days; reauthorization TARs may be granted in increments up to 15 days, not to exceed a total treatment duration of 120 calendar days; only one pump may be authorized for the 120-day period.

TAR must include a written prescription signed by the treating practitioner, a summary of medical condition, wound history and prior treatments, treatment plan, detailed wound descriptions and measurements, comorbidities, nursing care plan, and quantitative wound characteristics at least every 15 calendar days.

Requirements by wound type must be documented (moist wound environment ≥2 weeks without progression or healing; debridement as appropriate; specific criteria for stage III/IV pressure ulcers, diabetic ulcers, venous wounds, acute/traumatic wounds).

Contraindications such as necrotic tissue with eschar, untreated osteomyelitis at wound site, malignancy in wound, or inadequate circulation to the wound site preclude coverage.

Continued authorization requires evidence of significant wound improvement with dated assessment and description of interventions provided.

Osteogenesis stimulator coverage criteria

Osteogenesis stimulators (electrical and low-intensity ultrasound) are covered when ALL applicable criteria below are met:

Authorization is required and a dated practitioner order must be kept on file; claims must include an ICD-10-CM code describing the condition and location requiring the device. Devices are purchase-only and billed with modifier NU and KF (as designated).

Non-spinal electrical stimulators (E0747) coverage

Covered for nonunion long bone fractures only if: radiographic evidence the fracture healing has ceased, ≥6 months since fracture, X-rays over last 3 months show no healing, ≥6 months since alternative treatment started, fracture gap ≤1 cm, adequate immobilization and compliance, skeletally mature or ≥20 years (with infantile pseudarthrosis exception).

Spinal electrical stimulators (E0748) coverage

Covered for failed spinal fusion (≥9 months since last surgery), multi-level fusion (≥3 vertebrae), prior failed fusion at same site, or high-risk patients; device should be applied within 30 days as adjunct to fusion and used ≥2 hours/day for 270 consecutive days.

Ultrasound osteogenesis stimulator (E0760) coverage

Covered when nonunion of a fracture (not skull/vertebrae) in a skeletally mature person is documented by at least two radiograph sets separated by ≥90 days showing no clinically significant healing, fracture is not tumor-related; also specified fresh tibial diaphyseal or distal radius fractures criteria apply; device may not be used concurrently with other noninvasive stimulators.

Other DME items

Other specialized DME items have specific coverage restrictions and must meet listed criteria:

HCPCS S8265 (Haberman Feeder) reimbursable with maximum age one year and limited to specified diagnosis codes (G52.7, P92.1–P92.9, Q35.1–Q37.9).

HCPCS E0201 (penile contracture device, manual) reimbursable only for males age ≥18 with ICD-10-CM N48.6.

Pulsed Irrigation Enhanced Evacuation (PIEE) may be authorized for neuropathic bowel patients who have failed conservative bowel control attempts; documentation and TAR rules apply.

Ultrasonic osteogenesis stimulator (E0760)

Ultrasonic osteogenesis stimulator (E0760) is covered when ALL of the following are met:

Nonunion of a fracture (other than skull or vertebrae) in a skeletally mature person is documented by a minimum of two sets of radiographs obtained prior to treatment, separated by at least 90 days, with practitioner interpretation showing no clinically significant healing.

The fracture is not tumor-related.

Additional eligible fracture indications

Fresh (<7 days) closed or grade I open tibial diaphyseal fractures.
Fresh (<7 days) closed distal radius (Colles) fractures.

Device may not be used concurrently with other noninvasive stimulators and will be denied if the criteria above are not met.

PIEE criteria

PIEE (E0350/E0352) authorization and documentation requirements:

PIEE may be authorized for neuropathic bowel due to neurologic problems predisposing to severe fecal impaction after failure of traditional/conservative bowel control attempts.

Initial authorization includes a two-month rental trial to document effectiveness; following the two-month rental, a TAR must be submitted for purchase; separate TARs may be required for related services, equipment, and supplies; subsequent TARs may be approved in up to six-month increments with documentation of ongoing need and effectiveness.

Documentation must include complete history and physical, documentation of adequate caregiver support for training, and arrangement for skilled nursing/home health visits as needed.

Positioning seat (T5001) TAR criteria

Positioning seat (T5001) TAR criteria — ALL of the following must be met:

Member is unable to sit safely in conventional seating (seat, chair, booster seat, or highchair).

Member requires specialized positioning to safely perform essential activities of daily living as applicable for age.

Member exhibits one or more severe neuromotor/postural conditions (significant head/trunk instability, tone abnormalities, absence of protective reactions, inability to maintain unsupported sitting, etc.).

Therapeutic positioning seat is prescribed by a physician and a specialized seating/mobility evaluation has been performed by a therapist or an independent professional separate from the vendor supplying the equipment.

Portable ramp (E1399) coverage criteria

Portable ramp (E1399) TAR and documentation requirements — ALL of the following must be provided:

Recipient requires a wheelchair for home/community mobility and requires access to vehicles or primary entrance (community mobility).

TAR includes prior means of wheelchair access used, schematic drawing of residence with measurements comparing possible access sites, justification for least-cost access site and ramp type, catalog pages and invoice, mock-up trial details, and documentation of weight specifications and capacity.

Onsite evaluation demonstrates that caretaker can transport/setup ramp and the wheelchair can be used safely on the ramp. Fixed or attached ramps and home modifications are not covered.

Scales (E1639) coverage

Scales (E1639) coverage and billing criteria — ALL of the following must be met:

Recipient lacks access to a scale and meets at least one of: enrolled in Medi‑Cal Diabetes Prevention Program, is pregnant, or has a medical condition requiring ongoing home weight monitoring.

Adequate documentation in the medical record indicates the need for a home scale and lack of access to a scale.

HCPCS E1639 must be billed with modifier NU (purchase) only; a TAR is not required unless purchase is $100.00 or more; claim must include statement that recipient lacks access to a scale in Box 19 or attachment.

TheraTogs (A9900)

TheraTogs billing and TAR requirements:

TheraTogs claims must be billed with HCPCS code A9900, reimbursable 'By Report' and require a Treatment Authorization Request (TAR).

The subject 'TheraTogs' must be entered in the Additional Claim Information field (Box 19) and the item is taxable, which must be indicated on the claim.

TENS (E0720/E0730, A4595) coverage

TENS units and supplies coverage and medical necessity criteria:

The practitioner ordering the TENS unit must be the treating practitioner for the condition justifying TENS therapy.

Coverage categories

Acute post-operative pain: covered as rental only for up to 30 days from day of surgery (E0720/E0730 rental).
Chronic, intractable pain (other than chronic low back pain): covered when pain ≥3 months, etiology accepted as responsive to TENS, and other treatments tried and failed; trial use minimum 1 month and not to exceed 2 months, reimbursed as rental with monitoring.

TENS therapy for acute pain other than post-operative pain (less than 3 months) and for chronic low back pain is denied as not reasonable and necessary.

E0720 and E0730 are rental-only devices; after 10 months of rental they are considered patient-owned. Supplies A4595 reimbursable for patient-owned supplies only; supplies and repairs are not separately paid during the rental period.

Supply reimbursement (A4595) contingent on use with a covered TENS unit: usual maximum one A4595/month for 2‑lead, two A4595/month for 4‑lead; replacement lead wires (A4557) replacement more often than every 12 months is rarely reasonable.

TAR is required for E0720/E0730; initial TAR approved for specified trial periods and additional TARs required as outlined.

TENS coverage and medical necessity

Detailed medical necessity and trial requirements for TENS (when applicable):

Treating practitioner must be the treating practitioner for the disease/condition justifying the TENS device.

Acute post-operative pain: rental-only coverage for up to 30 days from day of surgery; other acute pain <3 months (non-post-op) is denied.

Chronic intractable pain (except chronic low back pain): pain present ≥3 months, etiology likely responsive to TENS, other treatments tried and failed; trial of 1–2 months reimbursed as rental and monitored for effectiveness; purchase coverage requires documentation of likely long-term benefit.

Chronic low back pain is not covered (denied as not reasonable and necessary).

Supplies: usual maximums—one A4595/month for 2‑lead, two A4595/month for 4‑lead; reduce billing frequency proportionally if use is less than daily; supplies only reimbursable when used with a covered TENS unit.

During the rental period, supplies and repairs for E0720/E0730 are not separately paid; after 10 months the device is considered patient-owned.

TAR is required for initial and continued rental periods as specified by the TAR guidance.

Tumor Treating Field Devices (E0766/E0767)

Tumor Treating Field Devices (E0766/E0767) coverage and authorization criteria:

HCPCS E0766 is reimbursable for treatment of newly diagnosed glioblastoma in adults meeting specified clinical criteria.

Patient criteria for E0766: age ≥18; histologically confirmed supratentorial glioblastoma; Karnofsky Performance Status ≥60; therapy delivered with temozolomide after maximal debulking surgery and completion of radiation; patient/caregiver trained and willing to apply device and wear device ≥18 hours/day.

An approved TAR is required for reimbursement; initial TAR may be authorized for up to three months; reauthorization requires MRI within four months showing no progression, KPS ≥60, and documented device use ≥18 hours/day.

Billing: E0766 must be billed with modifiers RR and KF as designated.

HCPCS E0767 reimbursement requires an approved TAR (see TAR requirement) and follows listed frequency limits where applicable.

Wearable Cardiac Defibrillator (K0606)

Wearable Cardiac Defibrillator (K0606) coverage notes:

HCPCS K0606 (wearable cardiac defibrillator) is reimbursable as rental-only on a monthly basis and requires authorization; must be billed with modifier RR and KF; purchase (NU) or repair/replacement (RB) modifiers are not allowed.

The rental rate is all-inclusive of listed components (monitor/defibrillator, garment, electrodes, batteries, charger, holster, modem) and separate reimbursement for these components or A9900 is not allowed.

Authorization criteria are available in the Cardiology section of the Part 2 provider manual.

Ultraviolet Light Therapy

Ultraviolet light therapy is considered medically necessary when ALL of the following are met:

Beneficiary has severe, widespread or moderate-to-severe psoriasis not adequately controlled by other treatments and is diagnosed with one of the listed ICD-10-CM codes.

Other treatments (topical corticosteroids, coal tar, or office-based therapy) have failed and home-based therapy is likely to succeed or patient cannot attend office-based therapy due to serious medical/physical limitations.

Treatment is conducted under the prescribing practitioner's supervision with regularly scheduled exams, is expected to be long term, and evidence of improvement (clear photographs acceptable) is provided; lack of compliance or lack of improvement renders the device not medically necessary.

HCPCS codes E0691 and E0694 describe covered UV therapy systems and must be billed with modifier NU (purchase) or RB (repair); mutual exclusivity and frequency rules apply (one in five years frequency limit per code and taxable status as indicated).

Ultraviolet light therapy coverage criteria

Ultraviolet light therapy coverage criteria and billing limitations:

Beneficiary must be diagnosed with one of the listed ICD-10-CM codes appropriate for moderate to severe or widespread psoriasis and other treatments have failed.

Treatment is supervised by the prescribing practitioner with regularly scheduled exams and expected to be long-term; patient must meet eligibility conditions (unable to attend office-based therapy, prior treatment failure, or frequent flares requiring immediate treatment).

Clear photographs as proof of improvement are acceptable; lack of compliance or improvement makes the device not medically necessary.

Billing rules: HCPCS E0691 and E0694 must be billed with modifier NU or RB; these codes are mutually exclusive within the same month and subject to a frequency limit of one unit per code every five years; codes are taxable.

HCPCS and Related Codes

General DME coding referencesmixed

No codes listed

Walkers and AccessoriesHCPCSCovered

E0130-E0149	Walkers (various types) and associated Column II accessories included in purchase reimbursement
E0150	Combination wheeled walker with seat and transport chair; use for members 21 years of age or younger

Gait TrainersHCPCS

E8000	Gait trainer, pediatric size, posterior support, includes all accessories and components
E8001	Gait trainer, pediatric size, upright support, includes all accessories and components
E8002	Gait trainer, pediatric size, anterior support, includes all accessories and components

Gait Modulation DevicesHCPCS

E3200

Gait modulation system, rhythmic auditory stimulation, prescription only

DME for Disabled Parent Billingmixed

A9999	Miscellaneous DME supply or accessory, not otherwise specified (used for DME for disabled parent)
Z73.6	ICD-10-CM code required for claims for DME for disabled parent
SC	modifier required when billing DME for a disabled parent

Hospital bed and accessory HCPCS codes and billing constraintsHCPCSCovered

E0271	mattress, inner spring
E0272	mattress, foam rubber
E0305	bedside rails; half length
E0310	bedside rails; full length
E0303	hospital bed, heavy duty, extra wide, w/ weight capacity >350 lbs ≤600 lbs, with any type side rails, with mattress
E0304	hospital bed, extra heavy duty, extra wide, w/ weight capacity >600 lbs, with any type side rails, with mattress
E0328	hospital bed, pediatric, manual, 360 degree side enclosures, includes mattress
E0329	hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, includes mattress
E0316	safety enclosure frame/canopy for use with hospital bed, any type
E0300	pediatric crib, hospital grade, fully enclosed

Standing systems / standersHCPCSCovered

E0637	Combination sit to stand system, any size, with seatlift feature
E0638	Standing frame system, one position, any size
E0641	Standing frame system, multi-position, any size
E0642	Standing frame system, mobile (dynamic stander), any size

Multi-positional patient transfer systemsHCPCSCovered

E1035	Multi-positional patient transfer system, up to 300 lbs
E1036	Multi-positional patient transfer system, extra-wide, >300 lbs

Stairway chairliftsHCPCS

E1399

Stairway chairlift (report by report)

Phototherapy lightHCPCS

E0202

Phototherapy (bilirubin) light with photometer

Pneumatic compressors / lymphedema pumps (examples)HCPCS

E0650	Pneumatic compressor, nonsegmental home model
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure

DME and related supply codes referenced in this portionHCPCS

E0650	Pneumatic compressor, nonsegmental home model
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure
E0655	Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm
E0656	Segmental pneumatic appliance for use with pneumatic compressor, trunk
E0657	Segmental pneumatic appliance for use with pneumatic compressor, chest
E0658	Segmental pneumatic appliance integrated (2 full arms and chest)
E0659	Segmental pneumatic appliance integrated (head, neck and chest)
E0660	Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg
E0665	Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm
E0666	Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

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Breastfeeding suppliesHCPCSCovered

A4287	Disposable collection and storage bag for breast milk, each
T2101	Human breast milk processing, storage and distribution, billed per 3 ounces

Cough stimulating device suppliesHCPCSCovered

A7020	Interface for cough stimulating device, includes all components, replacement only
E0482	Alternative positive and negative airway pressure (cough stimulating device)

NPWT devices and suppliesHCPCSCovered

E2402	Negative pressure wound therapy electrical pump, stationary or portable (daily rental only)
A6550	Wound care set for NPWT electrical pump
A7000	Canister, disposable, used with suction pump, each
A7001	Canister, non-disposable, used with suction pump, each
K0743	Suction pump, home model, portable, for use on wounds
K0744	Absorptive wound dressing for use with suction pump, pad size 16 sq in
K0745	Absorptive wound dressing for use with suction pump, intermediate size
K0746	Absorptive wound dressing for use with suction pump, large size

Osteogenesis stimulatorsHCPCS

E0747	Non-spinal electrical osteogenesis stimulator
E0748	Osteogenesis stimulator, electrical, non-invasive, spinal applications
E0760	Osteogenesis stimulator, low intensity ultrasound, non-invasive

Ultrasound osteogenesis stimulatorHCPCSCovered

E0760

Osteogenesis stimulator, low intensity ultrasound, non-invasive

PIEE equipment and disposable kitsHCPCSCovered

E0350	Control unit for electronic bowel irrigation/evacuation system (PIEE)
E0352	Disposable therapy pack for PIEE

Positioning seatHCPCS

T5001

Special orthotic positioning seat

Portable rampsHCPCS

E1399

Durable medical equipment, miscellaneous (portable ramps)

ScalesHCPCS

E1639

Scale, patient home use

TheraTogs billingHCPCS

A9900

Miscellaneous DME supply/accessory (used for TheraTogs)

TENS units and suppliesHCPCS

A4595	Electrical stimulator supplies, 2 lead, per month (reimbursable for patient-owned only)
E0720	Transcutaneous electrical nerve stimulation device, two lead, localized stimulation (rental only)
E0730	Transcutaneous electrical nerve stimulation device, four or more leads (rental only)

TENS codesHCPCSCovered

A4595	Electrical stimulator supplies, 2 lead, per month (reimbursable for patient-owned only)
E0720	Transcutaneous electrical nerve stimulation device, two lead, localized stimulation (rental only)
E0730	Transcutaneous electrical nerve stimulation device, four or more leads (rental only)

Tumor treating field device codesHCPCSCovered

E0766

Electrical stimulation service used for cancer treatment, includes all accessories (reimbursable for newly diagnosed glioblastoma)

E0767HCPCSCovered

E0767

Intrabuccal amplitude-modulated RF electromagnetic field device for cancer treatment (includes accessories); frequency one every five years

Wearable Cardiac DefibrillatorHCPCSCovered

K0606

Automatic external defibrillator, garment type (wearable cardiac defibrillator) — rental-only; billed with RR and KF

Ultraviolet light therapy codesHCPCSCovered

E0691	Ultraviolet light therapy system, includes bulbs, lamps, timer and eye protection; treatment area two square feet or less
E0694	Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs, lamps, timer and eye protection

Ultraviolet light therapy systemsHCPCSCovered

E0691	Ultraviolet light therapy system, includes bulbs, lamps, timer and eye protection; treatment area two square feet or less
E0694	Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs, lamps, timer and eye protection

Gait modulation device frequency

Replacement frequencyOne every five years

Applicable HCPCSE3200 (gait modulation system) per coding table

Prior authorizationAn approved TAR is required for gait modulation devices

Minimum head elevation

Minimum head elevationAt least 30 degrees (≥30°) required for hospital bed coverage

ContextRequired when needed for conditions such as CHF, COPD, or documented history of aspiration

ExclusionBed not covered if head elevation is less than 30 degrees; pillows/wedges must be ruled out

Weight thresholds

Heavy‑duty extra‑wide weight range351–600 pounds

Extra heavy‑duty weight threshold>600 pounds

Coverage requirementRecipient must meet fixed‑height hospital bed coverage criteria in addition to weight requirement

patient weight threshold for E1036

Patient weight threshold for E1036>300 pounds

Code descriptionE1036 = multi‑positional patient transfer system, extra‑wide, with integrated seat

AuthorizationCode E1036 requires a Treatment Authorization Request (TAR)

bed weight categories

Heavy‑duty extra‑wide351–600 lbs

Extra heavy‑duty>600 lbs

RequirementMust also meet fixed‑height hospital bed coverage criteria

TAR threshold for E0607

TAR requirement thresholdAuthorization required for E0607 only when cost exceeds established TAR threshold limits for rental or purchase

Documentation must includeICD‑10 diagnosis codes and written statement that the requested glucometer is the least costly item to meet medical needs

Special‑feature monitorsE2100/E2101 always require authorization

Replacement limit for A4281–A4286

Replacement limit (A4281–A4286)Up to two replacements per recipient per 12 months without TAR

Billing modifierThese items must be billed with modifier NU (purchase) only and reimbursement is 'By Report'

DocumentationProviders must document specific item(s) replaced and malfunction details in recipient record

Frequency limit for A4287

Frequency limit (A4287)120 bags per infant without TAR

Use caseReimbursable when medically necessary (e.g., infant unable to latch); mother's Medi‑Cal ID may be used initially

Additional supply needIf more bags needed submit TAR using infant's Medi‑Cal ID; claim must state pump is patient‑owned

T2101 daily volume limit

Daily volume limit (T2101)35 ounces per day (billed per 3‑ounce unit); coverage up to 12 months of age

Billing unitT2101 billed per 3 ounces

SourcingPDHM must be obtained from a licensed and approved facility

A6550 frequency limit

A6550 monthly frequency limit15 wound care sets per month (reimbursable for purchase only)

Billing noteAll may be dispensed on the same date as appropriate; A6550 reimbursable for purchase only

AssociationUsed with NPWT electrical pump (E2402)

A4479 frequency limit

A4479 frequency limitOne device every two years

AuthorizationAn approved TAR is required for reimbursement of A4479

Billing modifiersModifier NU required; RB and RA are allowable

PIEE initial rental trial

Initial rental trial (PIEE)2 months (initial rental trial before purchase TAR required)

Post‑trial actionFollowing the two‑month rental, a TAR must be submitted for purchase if long‑term use is indicated

Subsequent TARsSubsequent TARs for services and supplies may be approved for up to six‑month increments with documentation

TENS rental period to ownership

Rental period to ownership (TENS E0720/E0730)After 10 months of rental, E0720/E0730 are considered patient‑owned

Supply reimbursement (A4595)A4595 reimbursable for patient‑owned supplies only

Rental billing noteSupplies and repairs are not separately paid during the rental period

Scale TAR requirement threshold

Scale TAR thresholdTAR not required unless purchase is $100.00 or more

Billing modifierE1639 must be billed with modifier NU when purchased and include statement that recipient lacks access to a scale

Coverage criteriaRecipient must lack access to a scale and meet program‑specific conditions (e.g., pregnancy, diabetes program, ongoing home weight monitoring)

E0767 frequency

E0767 frequencyOne every five years

Age and diagnosis requirementsMust be 22 years of age or older; ICD‑10‑CM diagnosis code C22.0 required

Billing modifiersModifiers NU, RB, RR and KF are required for E0767

Frequency limit

General frequency limitOne unit per code every five years

ApplicabilityApplies to specified device codes where frequency limit is stated as one in five years (e.g., E0691/E0694, E1035/E1036, E0767)

Tax status noteSome codes with this frequency are taxable (see individual code billing rules)

Authorization, Documentation, and Billing Requirements

Documentation Required

Authorization, service date, and shipping rules

Authorization for durable medical equipment is limited to the lowest cost item that meets the patient’s medical needs per CCR Title 22, Section 51321(g). The date the recipient takes receipt of the DME item is the date of service (date of delivery = date of service). Shipping and handling charges are not reimbursable.

Prior Authorization

TAR required for gait trainers with specified clinical documentation

Submit a Treatment Authorization Request (TAR) for gait trainers; include a copy of the written prescription and adequate medical record documentation (PT evaluation) showing licensed PT evaluation, purposeful use, partial weight bearing and ability to advance lower extremities, need for greater structural/postural support than a walker, satisfactory head control, and absence of other self‑initiated mobility.

Prior Authorization

TAR required for gait modulation devices

An approved Treatment Authorization Request (TAR) is required for reimbursement of gait modulation devices.

Prior Authorization

TAR and disability documentation required for DME for a disabled parent

A TAR is required for DME provided to assist a disabled parent; the TAR must include the treating practitioner’s prescription and documentation from the recipient’s physician, nurse practitioner, clinical nurse specialist or physician assistant of the recipient’s medical disability.

Billing Rule

Billing and TAR requirements for DME for a disabled parent (A9999, Z73.6, modifier SC)

When billing DME for a disabled parent, submit a TAR with the treating practitioner’s prescription and medical disability documentation, and submit claims using HCPCS A9999 with ICD‑10‑CM diagnosis Z73.6 and modifier SC.

Prior Authorization

TAR required for E1036

HCPCS code E1036 (extra‑wide multi‑positional patient transfer system, >300 lbs) requires a Treatment Authorization Request (TAR) for authorization.

Prior Authorization

TAR content and mandatory rental period for standing systems

TARs requesting standing systems (E0637, E0638, E0641, E0642) must include diagnosis, age/size (height/weight), description of functions/transfers/goals/daily activities, relevant impairments and history; a three‑month rental is mandatory before purchase unless the recipient participated in a community standing program as specified.

Prior Authorization

Authorization and initial 60‑day trial rental for lymphedema pumps

All lymphedema pumps and pneumatic compression devices listed (e.g., E0650–E0669, E0671–E0673, E0678–E0682) require authorization and an initial 60‑day trial rental to establish clinical effectiveness.

Prior Authorization

Case‑by‑case TAR review for stairway chairlifts (E1399)

Each TAR for a stairway chairlift (E1399) is adjudicated case‑by‑case considering medical necessity, cost, less‑costly options, and the recipient’s/caregiver’s ability to independently and safely operate the chairlift.

Billing Rule

Phototherapy (E0202) — rental coverage and RR modifier required

Phototherapy light (HCPCS E0202) is covered as a daily rental only when medically necessary and must be billed with modifier RR.

Prior Authorization

Authorization requirements for segmental pneumatic appliances and specified monitors

Authorization is required for segmental pneumatic appliances (e.g., E0656, E0657) and for E0678–E0682; TAR must include required documentation and appropriate ICD‑10 codes. Authorization is also required for glucometers with special features (E2100, E2101); authorization for E0607 is required when cost exceeds TAR threshold limits.

Billing Rule

Lifetime reimbursement limit and billing modifiers for E0656/E0657

HCPCS codes E0656 and E0657 are restricted to once‑in‑a‑lifetime reimbursement per recipient (any provider) and must be billed with modifier NU for purchase, RR for rental, or RB for repair/replacement.

Prior Authorization

TAR timing and reauthorization rules for NPWT

NPWT pumps and supplies require a TAR. Initial TAR for the pump may be granted for up to 15 days; reauthorization TARs may be granted in up to 15‑day increments not to exceed a total of 120 calendar days.

Documentation Required

Document patient‑owned status on claims for certain supplies

When billing for certain supply codes that are used with patient‑owned equipment (for example A4287 breast milk bags, A4556/A4557 electrodes/lead wires), include a statement on the claim (Box 19) or an attachment that the equipment is patient‑owned.

Denial Risk

Denial risk: incompatible supply codes with E0482; use A7020

Do not bill codes A7027–A7046 with E0482 — such claims will be denied; use A7020 for the interface/replacement for cough stimulating devices and note that A7020 is not separately reimbursable when billed with the rental/initial purchase of the cough device.

Prior Authorization

PIEE initial 2‑month rental trial and TAR requirements for purchase and services

PIEE equipment (E0350) and disposable packs (E0352) require authorization; the device has an initial two‑month rental trial, after which a TAR must be submitted for purchase; separate TARs may be required for PIEE‑related services and supplies, with subsequent TARs approved up to six‑month increments with documentation.

Prior Authorization

Authorization and billing modifiers required for positioning seat (T5001)

HCPCS code T5001 (positioning seat) requires authorization, must be billed 'By Report,' and must be billed with modifier NU (purchase), RR (rental) or RB (repair/replacement); claims billed with RB must document patient ownership.

Prior Authorization

Scale TAR threshold and NU modifier billing requirement (E1639)

A TAR is not required for scale (E1639) reimbursement unless the purchase is $100.00 or more. When billed, E1639 must be billed with modifier NU and include a statement in the claim that the recipient lacks access to a scale.

Prior Authorization

TAR and documentation requirements for portable ramps (E1399); exclusions

Portable ramps billed with HCPCS E1399 require a TAR with medical justification and extensive supporting documentation including prior wheelchair access used, residence schematic and measurements, least‑cost access justification, catalog pages, invoice, mock‑up trial details, and weight/capacity specifications; fixed or attached ramps and home modifications are not covered.

Prior Authorization

TAR required for TENS (E0720/E0730); initial 1‑month rental post‑surgery

A Treatment Authorization Request (TAR) is required for TENS device codes E0720 and E0730. TAR is approved for one month of rental post‑surgery only; an initial one‑month TAR establishes effectiveness and an additional TAR is required for subsequent months up to the provider‑documented total.

Prior Authorization

TAR and reauthorization criteria for E0766

An approved Treatment Authorization Request (TAR) is required for reimbursement of Tumor Treating Field Device code E0766. The initial TAR may be authorized for up to three months and reauthorization requires MRI within four months showing no progression, KPS ≥60, and device use ≥18 hours/day.

Prior Authorization

TAR required for E0767

An approved Treatment Authorization Request (TAR) is required for reimbursement of HCPCS code E0767.

Billing Rule

Authorization and rental‑only billing rules for wearable cardiac defibrillator (K0606)

Code K0606 (wearable cardiac defibrillator) is reimbursable as rental‑only and is subject to authorization; bill monthly with modifier RR and KF; purchase (NU) or repair/replacement (RB) billing is not allowed and separate reimbursement for listed components is not allowed.

Prior Authorization

Prior authorization (TAR) required where indicated

An approved Treatment Authorization Request (TAR) is required for reimbursement of items and codes listed throughout this section where the policy indicates TAR is required (see individual code entries).

Definitions and Policy Terms

date of delivery / date of service

Date of delivery definitionThe date the recipient takes receipt of the DME item is considered the date of service for billing

Service dating implicationUse date of delivery as the service date on claims

Related ruleAuthorization limited to the lowest cost item that meets the patient's medical needs per CCR Title 22 §51321(g)

shipping and handling

Shipping & handling ruleCharges for shipping and handling are not reimbursable under this policy

Claim preparationExclude shipping and handling charges when calculating billed amount

Regulatory basisStated in General policy section of the manual

Gait Trainer

DefinitionA gait trainer is a mobile external, fixed base of support providing extensive trunk/postural and/or pelvic stability to allow mobility

Typical codesGait trainers billed with HCPCS E8000–E8002 (pediatric sizes) and require TAR

Clinical requirementUsed when greater support than a walker is required and patient can partially bear weight and advance lower extremities

Treatment Authorization Request required for DME provided for a disabled parent

TAR requiredA Treatment Authorization Request (TAR) is required for DME provided to assist a disabled parent

Documentation requiredTAR must include prescription and documentation of recipient's medical disability from physician/NP/CNS/PA

Billing codesClaims must use HCPCS A9999, ICD‑10‑CM Z73.6 and modifier SC

Beds that electronically control head and knee sections and manually adjust height (noted for E0303, E0304 and all heavy duty beds)

Beds with electronic head/knee controlSemi‑electric beds electronically control head and knee sections and manually adjust height (not a total electric benefit)

Codes notedE0303, E0304 and all heavy duty beds are semi‑electric

Accessory billing noteMattress and bedrail codes (E0271/E0272/E0305/E0310) not reimbursable if billed with E0303/E0304; payment limited to bed code allowance

E0316 (safety enclosure frame) is not separately reimbursable when billed with E0300 (pediatric crib, hospital grade, fully enclosed)

E0316 reimbursement ruleHCPCS E0316 (safety enclosure frame/canopy) is not separately reimbursable when billed with HCPCS E0300 (pediatric crib, hospital grade, fully enclosed)

Provider implicationDo not bill E0316 separately for same recipient with E0300; combined payment handled with E0300

Audit noteClaims subject to review for improper separate billing

Total Electric

Total Electric statusTotal Electric hospital bed is mostly for convenience and is not a Medi‑Cal benefit

Coverage implicationTotal Electric beds are generally not covered under Medi‑Cal

ContrastSemi‑electric heavy duty beds (E0303/E0304) are covered when criteria met

Standers / standing frames

Standers / standing frames definitionDevices that allow wheelchair‑dependent patients to achieve a passive standing position and are Medi‑Cal benefits subject to authorization

Typical HCPCSE0637, E0638, E0641, E0642

TAR and trial rulesTAR must include clinical/functional info; mandatory three‑month rental before purchase unless prior community standing program participation

Lymphedema pumps/compression devices contraindications

ContraindicationsLymphedema pumps/compression devices contraindicated in presence of active infection or deep vein thrombosis in affected limb

Coverage prerequisitesConfirmed primary or secondary lymphedema with functional impairment and failure of ≥30 days of conservative therapy

AuthorizationPurchase or continued rental may be authorized when documented effectiveness is shown

Breast pumps definitions and requirement

Breast pump definitions and requirementBreast pumps (E0602, E0603, E0604) must include all necessary supplies and be the lowest‑cost option meeting medical necessity

Supply billing rulesReplacement parts A4281–A4286 and A4288 billed NU (purchase) only; reimbursement 'By Report' and up to two replacements per 12 months without TAR

Disposable bags and donor milkA4287 reimbursable up to 120 bags per infant without TAR; T2101 covers pasteurized donor human milk (35 oz/day, billed per 3 oz unit) up to 12 months

TAR required for certain DME items (definition)

TAR required definitionTAR is required for specified DME items (e.g., NPWT pumps and supplies); initial and reauthorization rules apply per device-specific sections

NPWT exampleInitial TAR for NPWT pump granted up to 15 days; reauthorizations up to 15‑day increments not to exceed 120 days

Documentation expectationTARs must include detailed clinical history, wound descriptions, treatment plan and periodic quantitative wound measurements

Modifier NU / KF

Modifier use for E0300/E0766 etc.Tumor treating field devices (E0766) must be billed with modifier RR and KF; billing modifiers KF apply to FDA class III devices

E0316 relationSome accessory modifiers (NU/RB/RR) apply per device-specific billing rules

NoteRefer to individual code rules for exact modifier combinations

PIEE

PIEE definitionPIEE (pulsed irrigation enhanced evacuation) control unit and disposable therapy pack defined by HCPCS E0350/E0352

Initial trialInitial two‑month rental trial required to document medical necessity and effectiveness

TAR for purchaseFollowing two‑month rental a TAR must be submitted for purchase authorization

Ultrasonic osteogenesis stimulator

Ultrasonic osteogenesis stimulator definitionLow‑intensity ultrasound osteogenesis stimulator (HCPCS E0760), non‑invasive, per‑treatment reimbursement

Coverage caveatCovered only when strict radiographic and clinical criteria are met (nonunion, two radiograph sets ≥90 days apart, not tumor‑related)

Billing instructionMust be billed as purchase (modifier NU) though reimbursed per treatment; cannot be used concurrently with other noninvasive stimulators

TheraTogs

TheraTogs definitionTheraTogs is a garment and strapping application used to provide prolonged muscle stretch and alignment guidance

Billing codeUse HCPCS A9900; reimbursable 'By Report' and requires a TAR

Claim instructionsEnter 'TheraTogs' in Additional Claim Information (Box 19); item is taxable

patient-owned

Patient‑owned definitionAfter specified rental periods (e.g., TENS after 10 months) devices are considered patient‑owned for supply reimbursement rules

A4595 ruleA4595 reimbursable for patient‑owned supplies only

DocumentationClaims for patient‑owned supplies must document ownership in claim info (Box 19) or attachment when required

billing modifiers

Rental (RR) and purchase (NU) modifiersModifier RR indicates rental; NU indicates new purchase; RB indicates repair/replacement

KF modifierKF required for FDA‑designated class III devices (e.g., certain osteogenesis or tumor treating devices)

Code‑specific billingRefer to individual code descriptions for exact required modifier combinations

Ultraviolet light therapy medical necessity

Medical necessity (UV therapy)Ultraviolet light therapy is considered medically necessary for severe, widespread psoriasis not adequately controlled by other treatments

SupervisionTreatment must be under prescribing practitioner's supervision with regular exams and expected long‑term use

Evidence requirementPhotographic evidence of improvement may be required; lack of improvement or compliance renders device not medically necessary

Policy Summary

PayerCalifornia Department of Health Care Services

PolicyDurable Medical Equipment (DME): Other DME Equipment

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2023

Last ReviewMar 1, 2023

Next Review DateN/A

SourceLink

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Durable Medical Equipment (DME): Other DME Equipment

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Coverage and Medical Necessity Criteria for Other DME

Other DME items (overview)

Authorization for DME is limited to the lowest cost item that meets the patient's medical needs per CCR Title 22, Section 51321(g).

The date of delivery to the recipient is the date of service for billing purposes; shipping and handling charges are not reimbursable.

Coverage criteria for walkers, gait trainers, gait modulation devices, bathroom equipment, and DME for disabled parent

Covered when ALL of the following are met:

Gait trainer is prescribed and medically necessary for the recipient.

A written prescription signed by the treating practitioner (or electronic equivalent) accompanies the TAR or claim.

Providers bill gait trainers with HCPCS codes E8000–E8002 and submit a Treatment Authorization Request (TAR) as required.

Gait modulation devices (e.g., E3200) require an approved TAR and meet additional age, diagnosis, and modifier requirements as specified in the guidance.

Bathroom and related items

Bathroom assistive items may not be Medicare-covered; may be billed to Medi-Cal without prior Medicare denial per guidance.
Commode chairs (E0170/E0171) require TAR documentation of neuromuscular dysfunction or arthropathy and are subject to month-of-service restrictions.

DME to assist a disabled parent may be covered when TAR includes prescription and documentation of the recipient's medical disability; claims must use HCPCS A9999 with ICD-10 Z73.6 and modifier SC.

DME for a disabled parent

Covered when ALL of the following are met:

A Treatment Authorization Request (TAR) is submitted for DME provided to assist a disabled parent.

Claims for DME for a disabled parent must be submitted using HCPCS A9999, ICD-10-CM diagnosis code Z73.6, and modifier SC.

Reimbursement for such items follows the reimbursement policy associated with each specific DME item (purchase/rental/supply pricing) as described in the DME overview and related sections.

Hospital beds and pediatric enclosed beds — medical necessity criteria

Hospital or pediatric enclosed beds are covered when ALL applicable medical necessity criteria below are met:

The hospital bed is necessary to treat the documented medical condition and is expected to produce a positive medical outcome or prevent complications that would not occur without the bed.

The desired medical benefit cannot be attained by an ordinary bed nor by modifying an ordinary bed using commercially available items.

Pediatric enclosed bed additional criteria

Behavioral necessity is documented; behavioral interventions attempted without success; less restrictive alternatives tried and failed; an ordinary bed cannot be modified to meet needs; no other feasible alternative exists; request is not for caregiver convenience.

Variable-height bed: meets fixed-height criteria and requires height adjustment for transfers to chair/wheelchair or to standing.

Semi-electric bed: meets fixed-height criteria and requires frequent or immediate body position changes.

Heavy-duty extra-wide beds: meet fixed-height criteria and recipient weight is 351 to 600 pounds.

Extra heavy-duty beds: meet fixed-height criteria and recipient weight exceeds 600 pounds.

For CCS-managed children, requests are reviewed by CCS per Title 22 regulations.

Accessory billing restrictions

Billing restrictions and mutual exclusivity rules:

HCPCS E0316 (safety enclosure frame/canopy) is not separately reimbursable when billed for the same recipient with HCPCS E0300 (pediatric crib, hospital grade, fully enclosed).

Heavy-duty extra-wide hospital beds

Covered when ALL of the following are met:

The recipient meets the fixed-height hospital bed coverage criteria (see hospital bed criteria).

Recipient's weight is between 351 and 600 pounds.

Extra heavy-duty hospital beds

Covered when ALL of the following are met:

The recipient meets the fixed-height hospital bed coverage criteria (see hospital bed criteria).

Recipient's weight exceeds 600 pounds.

Hospital bed medical necessity and documentation

Documentation required to certify medical necessity:

Medical necessity must be clearly documented by the licensed practitioner; a signed prescription (or electronic equivalent) must accompany the TAR.

Clinical documentation must describe condition, severity/frequency of symptoms, expected therapeutic outcome, caregiver availability, and recipient's ability to operate the bed.

Providers must submit DHCS form 6181 Certificate of Medical Necessity for All DME (Except Wheelchairs and Scooters) or equivalent documentation containing the required information.

Standers/standing frames medical necessity

Standers/standing frames are covered when ALL of the following are met:

Device is not provided for recipients with complete paralysis of hips/legs when standing would not improve or maintain range of motion or would be unsafe.

TAR requirements and rental-to-purchase rule for standers

TAR requirements and rental-to-purchase rule:

A mandatory three-month rental period is required before purchase unless the recipient has participated in a community standing program three to four times per week for at least three months.

Patient transfer systems and stairway chairlifts coverage

Patient transfer systems and stairway chairlifts coverage criteria and TAR requirements:

HCPCS E1035 and E1036 are covered subject to coding, frequency, and TAR rules; E1036 requires a TAR and has a once-in-five-years frequency limit.

HCPCS E1035 and E1036 are not separately payable within the same month as code E0240 (bath/shower chair).

Reimbursement for stairway chairlifts (E1399) is 'By Report.'

Phototherapy coverage and limits

Phototherapy light (E0202) is covered when ALL of the following are met:

Infant's total serum bilirubin is in the 'optional range' per AAP guidelines, the infant is feeding/voiding/stooling well and appears well, and close follow-up evaluation is possible.

Coverage is as a daily rental only and must be billed with modifier RR.

Frequency limit is 10 days per lifetime per infant; a TAR can override frequency limits (for example, multiple infants) with appropriate claim documentation.

Claims may be submitted under the mother's Medi‑Cal ID when the infant's Medi‑Cal eligibility is not yet established; patient relationship must be indicated on the claim.

Lymphedema pumps / pneumatic compression devices

Lymphedema pumps and pneumatic compression devices are covered when ALL of the following are met:

Conservative therapies (elevation, exercise, massage, compression bandage/garment) have been tried for at least 30 days and failed, and the recipient has demonstrated compliance with past treatments.

Purchase or continued rental may be authorized when documented effectiveness is shown (pre- and post-treatment measurements or functional improvement).

Lymphedema pump/device coverage criteria

Clinical and prior-conservative-therapy criteria required for coverage:

Confirmed diagnosis of primary or secondary lymphedema documented in the medical record.

Lymphedema is associated with functional impairment.

At least 30 days of conservative treatments (elevation, exercise, massage, compression bandage/garment) have been tried and failed.

Recipient has demonstrated compliance with past recommended treatments.

Contraindications such as active infection or deep vein thrombosis in the affected limb preclude coverage.

Purchase or continued rental requires documentation of clinical effectiveness (pre-/post-treatment measurements or functional improvement).

Blood glucose monitors coverage and documentation

Home blood glucose monitors are covered when ALL of the following are met:

Covered diagnoses

Type I insulin-dependent diabetes.
Type II non-insulin-dependent diabetes.
Diabetes mellitus complicating pregnancy.
Gestational diabetes with intent to monitor blood glucose at home.

Monitors billed with HCPCS E0607 or E2104 (integrated cartridges); special-feature monitors billed with E2100/E2101; adjunctive alert systems billed E2102 with NU/RB modifiers where applicable.

Claims must include relevant ICD-10-CM diagnosis codes. For E0607, documentation of recipient or caregiver competency and that the device is for home use is required.

Integrated cartridges billed with A4271; test strips and other supplies billed per supply coding guidance in the Part 2 manual.

Blood pressure equipment billing stance

Billing stance (purchase-only rule):

If billed with modifier RR (rental) the claim will be denied.

Breastfeeding aids and supplies coverage and limits

Breastfeeding aids and supplies are covered when ALL of the following are met:

Breast pumps (E0602, E0603, E0604) include necessary supplies (tubing, adapter, bottle/cap, shield, locking ring) and must be the lowest-cost option that meets medical necessity.

Pasteurized donor human milk (T2101) is covered per 3-ounce unit, up to 35 ounces per day, coverage up to 12 months when medically necessary.

E0602 and E0603 require no TAR; labor charges K0739/K0740 are not separately reimbursable.

Breastfeeding supplies

Supply-specific criteria and limits:

HCPCS T2101 covers pasteurized donor human milk from licensed facility, billed per 3-ounce unit, with a 35-ounce per day limit and coverage up to 12 months of age.

Cough device and electrode supplies

Cough device and electrode supplies coverage and billing rules:

Use HCPCS A7020 for interfaces for cough stimulating devices (replacement only); A7020 is not separately reimbursable with the rental or initial purchase of the cough device.

Claims that bill codes A7027–A7046 with E0482 will be denied; A7020 is the correct supply code for replacement interfaces.

Electrodes (A4556) and lead wires (A4557) are reimbursable for patient-owned DME items except TENS units; provider must document ownership in Box 19 or attachment.

Electronic pump enema (A4479)

A4479 (electronic transanal irrigation system) is reimbursable with TAR and limits:

An approved TAR is required for HCPCS A4479 prior to reimbursement.

Diagnosis code on the TAR is limited to specified bowel/intestinal ICD-10-CM codes (K59.00, K59.01, K59.02, K59.03, K59.04, K59.09, K91.89, R15.9).

Frequency limit: one device every two years; Modifier NU required for purchase; Modifiers RB and RA are allowable.

NPWT coverage criteria

Negative Pressure Wound Therapy (NPWT) is covered when ALL of the following criteria and documentation requirements are met:

NPWT devices and supplies must be billed with the appropriate HCPCS codes (E2402, A6550, A7000, A7001, K0743–K0746) and follow the rental/purchase limitations specified.

Contraindications such as necrotic tissue with eschar, untreated osteomyelitis at wound site, malignancy in wound, or inadequate circulation to the wound site preclude coverage.

Continued authorization requires evidence of significant wound improvement with dated assessment and description of interventions provided.

Osteogenesis stimulator coverage criteria

Osteogenesis stimulators (electrical and low-intensity ultrasound) are covered when ALL applicable criteria below are met:

Non-spinal electrical stimulators (E0747) coverage

Covered for nonunion long bone fractures only if: radiographic evidence the fracture healing has ceased, ≥6 months since fracture, X-rays over last 3 months show no healing, ≥6 months since alternative treatment started, fracture gap ≤1 cm, adequate immobilization and compliance, skeletally mature or ≥20 years (with infantile pseudarthrosis exception).

Spinal electrical stimulators (E0748) coverage

Covered for failed spinal fusion (≥9 months since last surgery), multi-level fusion (≥3 vertebrae), prior failed fusion at same site, or high-risk patients; device should be applied within 30 days as adjunct to fusion and used ≥2 hours/day for 270 consecutive days.

Ultrasound osteogenesis stimulator (E0760) coverage

Covered when nonunion of a fracture (not skull/vertebrae) in a skeletally mature person is documented by at least two radiograph sets separated by ≥90 days showing no clinically significant healing, fracture is not tumor-related; also specified fresh tibial diaphyseal or distal radius fractures criteria apply; device may not be used concurrently with other noninvasive stimulators.

Other DME items

Other specialized DME items have specific coverage restrictions and must meet listed criteria:

HCPCS S8265 (Haberman Feeder) reimbursable with maximum age one year and limited to specified diagnosis codes (G52.7, P92.1–P92.9, Q35.1–Q37.9).

HCPCS E0201 (penile contracture device, manual) reimbursable only for males age ≥18 with ICD-10-CM N48.6.

Pulsed Irrigation Enhanced Evacuation (PIEE) may be authorized for neuropathic bowel patients who have failed conservative bowel control attempts; documentation and TAR rules apply.

Ultrasonic osteogenesis stimulator (E0760)

Ultrasonic osteogenesis stimulator (E0760) is covered when ALL of the following are met:

The fracture is not tumor-related.

Additional eligible fracture indications

Fresh (<7 days) closed or grade I open tibial diaphyseal fractures.
Fresh (<7 days) closed distal radius (Colles) fractures.

Device may not be used concurrently with other noninvasive stimulators and will be denied if the criteria above are not met.

PIEE criteria

PIEE (E0350/E0352) authorization and documentation requirements:

PIEE may be authorized for neuropathic bowel due to neurologic problems predisposing to severe fecal impaction after failure of traditional/conservative bowel control attempts.

Documentation must include complete history and physical, documentation of adequate caregiver support for training, and arrangement for skilled nursing/home health visits as needed.

Positioning seat (T5001) TAR criteria

Positioning seat (T5001) TAR criteria — ALL of the following must be met:

Member is unable to sit safely in conventional seating (seat, chair, booster seat, or highchair).

Member requires specialized positioning to safely perform essential activities of daily living as applicable for age.

Portable ramp (E1399) coverage criteria

Portable ramp (E1399) TAR and documentation requirements — ALL of the following must be provided:

Recipient requires a wheelchair for home/community mobility and requires access to vehicles or primary entrance (community mobility).

Onsite evaluation demonstrates that caretaker can transport/setup ramp and the wheelchair can be used safely on the ramp. Fixed or attached ramps and home modifications are not covered.

Scales (E1639) coverage

Scales (E1639) coverage and billing criteria — ALL of the following must be met:

Recipient lacks access to a scale and meets at least one of: enrolled in Medi‑Cal Diabetes Prevention Program, is pregnant, or has a medical condition requiring ongoing home weight monitoring.

Adequate documentation in the medical record indicates the need for a home scale and lack of access to a scale.

TheraTogs (A9900)

TheraTogs billing and TAR requirements:

TheraTogs claims must be billed with HCPCS code A9900, reimbursable 'By Report' and require a Treatment Authorization Request (TAR).

The subject 'TheraTogs' must be entered in the Additional Claim Information field (Box 19) and the item is taxable, which must be indicated on the claim.

TENS (E0720/E0730, A4595) coverage

TENS units and supplies coverage and medical necessity criteria:

The practitioner ordering the TENS unit must be the treating practitioner for the condition justifying TENS therapy.

Coverage categories

Acute post-operative pain: covered as rental only for up to 30 days from day of surgery (E0720/E0730 rental).
Chronic, intractable pain (other than chronic low back pain): covered when pain ≥3 months, etiology accepted as responsive to TENS, and other treatments tried and failed; trial use minimum 1 month and not to exceed 2 months, reimbursed as rental with monitoring.

TENS therapy for acute pain other than post-operative pain (less than 3 months) and for chronic low back pain is denied as not reasonable and necessary.

TAR is required for E0720/E0730; initial TAR approved for specified trial periods and additional TARs required as outlined.

TENS coverage and medical necessity

Detailed medical necessity and trial requirements for TENS (when applicable):

Treating practitioner must be the treating practitioner for the disease/condition justifying the TENS device.

Acute post-operative pain: rental-only coverage for up to 30 days from day of surgery; other acute pain <3 months (non-post-op) is denied.

Chronic low back pain is not covered (denied as not reasonable and necessary).

During the rental period, supplies and repairs for E0720/E0730 are not separately paid; after 10 months the device is considered patient-owned.

TAR is required for initial and continued rental periods as specified by the TAR guidance.

Tumor Treating Field Devices (E0766/E0767)

Tumor Treating Field Devices (E0766/E0767) coverage and authorization criteria:

HCPCS E0766 is reimbursable for treatment of newly diagnosed glioblastoma in adults meeting specified clinical criteria.

Billing: E0766 must be billed with modifiers RR and KF as designated.

HCPCS E0767 reimbursement requires an approved TAR (see TAR requirement) and follows listed frequency limits where applicable.

Wearable Cardiac Defibrillator (K0606)

Wearable Cardiac Defibrillator (K0606) coverage notes:

Authorization criteria are available in the Cardiology section of the Part 2 provider manual.

Ultraviolet Light Therapy

Ultraviolet light therapy is considered medically necessary when ALL of the following are met:

Beneficiary has severe, widespread or moderate-to-severe psoriasis not adequately controlled by other treatments and is diagnosed with one of the listed ICD-10-CM codes.

Ultraviolet light therapy coverage criteria

Ultraviolet light therapy coverage criteria and billing limitations:

Beneficiary must be diagnosed with one of the listed ICD-10-CM codes appropriate for moderate to severe or widespread psoriasis and other treatments have failed.

Clear photographs as proof of improvement are acceptable; lack of compliance or improvement makes the device not medically necessary.

HCPCS and Related Codes

General DME coding referencesmixed

No codes listed

Walkers and AccessoriesHCPCSCovered

E0130-E0149	Walkers (various types) and associated Column II accessories included in purchase reimbursement
E0150	Combination wheeled walker with seat and transport chair; use for members 21 years of age or younger

Gait TrainersHCPCS

E8000	Gait trainer, pediatric size, posterior support, includes all accessories and components
E8001	Gait trainer, pediatric size, upright support, includes all accessories and components
E8002	Gait trainer, pediatric size, anterior support, includes all accessories and components

Gait Modulation DevicesHCPCS

E3200

Gait modulation system, rhythmic auditory stimulation, prescription only

DME for Disabled Parent Billingmixed

A9999	Miscellaneous DME supply or accessory, not otherwise specified (used for DME for disabled parent)
Z73.6	ICD-10-CM code required for claims for DME for disabled parent
SC	modifier required when billing DME for a disabled parent

Hospital bed and accessory HCPCS codes and billing constraintsHCPCSCovered

E0271	mattress, inner spring
E0272	mattress, foam rubber
E0305	bedside rails; half length
E0310	bedside rails; full length
E0303	hospital bed, heavy duty, extra wide, w/ weight capacity >350 lbs ≤600 lbs, with any type side rails, with mattress
E0304	hospital bed, extra heavy duty, extra wide, w/ weight capacity >600 lbs, with any type side rails, with mattress
E0328	hospital bed, pediatric, manual, 360 degree side enclosures, includes mattress
E0329	hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, includes mattress
E0316	safety enclosure frame/canopy for use with hospital bed, any type
E0300	pediatric crib, hospital grade, fully enclosed

Standing systems / standersHCPCSCovered

E0637	Combination sit to stand system, any size, with seatlift feature
E0638	Standing frame system, one position, any size
E0641	Standing frame system, multi-position, any size
E0642	Standing frame system, mobile (dynamic stander), any size

Multi-positional patient transfer systemsHCPCSCovered

E1035	Multi-positional patient transfer system, up to 300 lbs
E1036	Multi-positional patient transfer system, extra-wide, >300 lbs

Stairway chairliftsHCPCS

E1399

Stairway chairlift (report by report)

Phototherapy lightHCPCS

E0202

Phototherapy (bilirubin) light with photometer

Pneumatic compressors / lymphedema pumps (examples)HCPCS

E0650	Pneumatic compressor, nonsegmental home model
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure

DME and related supply codes referenced in this portionHCPCS

E0650	Pneumatic compressor, nonsegmental home model
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure
E0655	Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm
E0656	Segmental pneumatic appliance for use with pneumatic compressor, trunk
E0657	Segmental pneumatic appliance for use with pneumatic compressor, chest
E0658	Segmental pneumatic appliance integrated (2 full arms and chest)
E0659	Segmental pneumatic appliance integrated (head, neck and chest)
E0660	Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg
E0665	Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm
E0666	Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

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Breastfeeding suppliesHCPCSCovered

A4287	Disposable collection and storage bag for breast milk, each
T2101	Human breast milk processing, storage and distribution, billed per 3 ounces

Cough stimulating device suppliesHCPCSCovered

A7020	Interface for cough stimulating device, includes all components, replacement only
E0482	Alternative positive and negative airway pressure (cough stimulating device)

NPWT devices and suppliesHCPCSCovered

E2402	Negative pressure wound therapy electrical pump, stationary or portable (daily rental only)
A6550	Wound care set for NPWT electrical pump
A7000	Canister, disposable, used with suction pump, each
A7001	Canister, non-disposable, used with suction pump, each
K0743	Suction pump, home model, portable, for use on wounds
K0744	Absorptive wound dressing for use with suction pump, pad size 16 sq in
K0745	Absorptive wound dressing for use with suction pump, intermediate size
K0746	Absorptive wound dressing for use with suction pump, large size

Osteogenesis stimulatorsHCPCS

E0747	Non-spinal electrical osteogenesis stimulator
E0748	Osteogenesis stimulator, electrical, non-invasive, spinal applications
E0760	Osteogenesis stimulator, low intensity ultrasound, non-invasive

Ultrasound osteogenesis stimulatorHCPCSCovered

E0760

Osteogenesis stimulator, low intensity ultrasound, non-invasive

PIEE equipment and disposable kitsHCPCSCovered

E0350	Control unit for electronic bowel irrigation/evacuation system (PIEE)
E0352	Disposable therapy pack for PIEE

Positioning seatHCPCS

T5001

Special orthotic positioning seat

Portable rampsHCPCS

E1399

Durable medical equipment, miscellaneous (portable ramps)

ScalesHCPCS

E1639

Scale, patient home use

TheraTogs billingHCPCS

A9900

Miscellaneous DME supply/accessory (used for TheraTogs)

TENS units and suppliesHCPCS

A4595	Electrical stimulator supplies, 2 lead, per month (reimbursable for patient-owned only)
E0720	Transcutaneous electrical nerve stimulation device, two lead, localized stimulation (rental only)
E0730	Transcutaneous electrical nerve stimulation device, four or more leads (rental only)

TENS codesHCPCSCovered

A4595	Electrical stimulator supplies, 2 lead, per month (reimbursable for patient-owned only)
E0720	Transcutaneous electrical nerve stimulation device, two lead, localized stimulation (rental only)
E0730	Transcutaneous electrical nerve stimulation device, four or more leads (rental only)

Tumor treating field device codesHCPCSCovered

E0766

Electrical stimulation service used for cancer treatment, includes all accessories (reimbursable for newly diagnosed glioblastoma)

E0767HCPCSCovered

E0767

Intrabuccal amplitude-modulated RF electromagnetic field device for cancer treatment (includes accessories); frequency one every five years

Wearable Cardiac DefibrillatorHCPCSCovered

K0606

Automatic external defibrillator, garment type (wearable cardiac defibrillator) — rental-only; billed with RR and KF

Ultraviolet light therapy codesHCPCSCovered

E0691	Ultraviolet light therapy system, includes bulbs, lamps, timer and eye protection; treatment area two square feet or less
E0694	Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs, lamps, timer and eye protection

Ultraviolet light therapy systemsHCPCSCovered

E0691	Ultraviolet light therapy system, includes bulbs, lamps, timer and eye protection; treatment area two square feet or less
E0694	Ultraviolet multidirectional light therapy system in six foot cabinet, includes bulbs, lamps, timer and eye protection