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Medical Supplies Procedure Codes & Coverage Guidelines

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New York State Medicaid coverage guidelines, procedure code additions, description clarifications, fees, and instructions for durable medical equipment, prosthetics, orthotics, and medical supplies effective July 1, 2026; applies to Elderplan/HomeFirst providers participating in NY Medicaid.

Policy Summary

Payerelderplan

PolicyMedical Supplies Procedure Codes & Coverage Guidelines

Policy CodePolicy N/A

Change TypeCodes & fee updatesquantity/frequency revisionsauthorization clarifications

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionRequest prior approval via the Bureau of Medical Review or IVR/Enteral Web Portal when quantity or frequency limits are exceeded and include supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

New procedure codes and fees were added for certain supplies including A4288 (valve for breast pump), A4295, A4296, and A4297 (intermittent urinary catheters and related items).

Descriptions for A4351 and A4352 were updated to clarify coating options (with or without coating, e.g., Teflon, silicone, or silicone elastomer).

Quantities/frequencies were changed for multiple supply codes (examples: A4364 quantity reduced from 8 to 4; many ostomy pouch codes changed from 15 or 30/50 to 20).

Fee for A4398 (ostomy irrigation bag) changed from $1.01 to $15.76.

Certain items require authorization via DVS, IVR, or are underlined to indicate prior approval requirements; modifiers guidance clarified for replacement/repair billing and limits.

1.0version

7/1/2026effective

A4288,A4295–A4297new codes

reductions notedqty limits

A4398 increasefee change

NYRx transitionNYRx

Coverage Criteria and Limits

General coverage and criteria

See the DMEPOS Policy Manual and the Medical Supplies Coverage Guidelines for full requirements, definitions, and payment basis. The DMEPOS manual provides participation, documentation, and billing rules that apply to the items in this section.

Coverage is governed by the DMEPOS Policy Manual (see eMedNY) and the Medical Supplies Coverage Guidelines; providers must follow definitions, participation requirements, and basis of payment in the DMEPOS manual.

Items in these guidelines are subject to the quantity, frequency, billing and prior approval rules specified in the Medical Supplies Coverage Guidelines and the Fee Schedule; when frequency/quantity limits are exceeded, prior approval with supporting medical documentation is required.

Authorization channels (DVS, IVR/Enteral Web Portal, underlined/prior approval indicators) and prior approval procedures described in the DMEPOS manual apply to codes listed in these sections.

Quantity, frequency, and repair/replacement coverage rules

Quantity, frequency, and repair/replacement rules apply as stated in the Coverage Guidelines and Fee Schedule; listed quantities are maximums per designated period and prior approval is required to exceed them.

Quantities shown on the Fee Schedule (Coverage Guidelines) are maximums (examples: ostomy pouch quantities revised to 20, disposable underpads reduced from 300 to 150); quantities are interpreted per the code's stated period (commonly per 30 days).see Fee Schedule

Frequency designators (F1–F28) define dispensing limits for each procedure code; if a member exceeds the frequency limit, prior approval must be requested with medical documentation supporting the exception.

Frequency table definitions are in the Coverage Guidelines.

Replacement/repair: '-RB' modifier and replacement/repair modifier rules apply as specified; repairs exceeding 25% of device price and replacements under specified windows require prior approval or are limited per modifier rules.

NYRx reimbursement transition

Pharmacy and DME supply reimbursement routing changed for most MMC members; items in Sections 4.1–5.0 are affected.

As of April 1, 2023, members enrolled in mainstream Medicaid Managed Care (MMC), HARP, and HIV-SNP receive pharmacy/DME supply reimbursement through NYRx or via DMEPOS FFS providers; items in Sections 4.1–4.3 and 5.0 are included in this transition.

The NYRx/FFS transition does not apply to Managed Long-Term Care (MLTC) plans (including PACE, MAP, Essential Plan, CHP); MMC member claims for included sections are to be billed directly to Medicaid via NYRx or DMEPOS FFS providers after the transition date.

All prior approval and authorization systems and procedures continue to apply for items after the NYRx transition as they do for FFS members.

Included accessories/components

Certain accessories and components are included in the base equipment Maximum Reimbursement Amount (MRA) and are not separately reimbursable within a defined window.

Accessories/components specified as included in a base code's MRA must be supplied with the initial equipment dispensing and are considered part of the base reimbursement.

No additional reimbursement will be made for included accessories or components within 90 days of dispensing the base item; if required within 90 days, the equipment provider must supply the accessory at no additional charge to the member.

Breast pump coverage criteria

Coverage of breast pumps and associated supplies is subject to device specifications, intended use, and replacement part rules.

Manual (E0602) and standard electric (E0603) breast pumps are purchase-only; hospital-grade pumps (E0604) are rental-only and limited to DME vendors.

Covered indication: breastfeeding individuals who need to establish and/or maintain milk supply; devices must be single-user, lowest-cost adequate option, and packaged with all necessary parts.

Device technical/safety requirements: must prevent suction >250 mmHg; E0603 must meet additional specifications (lightweight ≤10 lbs, UL listed, adjustable suction 50–250 mmHg, automatic suction release, variable cycling ≥30 cycles/min, single and double pumping, visible milk pathway, battery option).

Replacement parts (A4288) are reimbursable only when nonfunctional (torn, warped, discolored) and are not separately reimbursable within six months of the initial pump purchase; disposable collection/storage bags (A4287) and valve (A4288) covered for active pump users.

Incontinence coverage criteria

Incontinence products are covered when medical necessity is documented by the ordering practitioner and products meet NYS DOH product specifications; age-based and documentation exclusions apply.

Coverage requires medical necessity documented by the ordering practitioner and maintained in the member's medical record; fiscal orders must include a specific diagnosis code or claims will be denied.

Minimum product specifications (independent testing documentation maintained by the dispenser) include: no plastic-backed products; rewet rate <2.0 g; rate of acquisition (ROA) <60 seconds; retention capacity >250 g; breathable zones >100 cfm; closure system allowing multiple fastening/unfastening where applicable.

Diapers, liners, and underpads are not covered for children age three or younger because lack of bladder/bowel control is considered normal development for this age group.

Frequency and reimbursement routing

Frequency limits are specified per-code by superscript notation; claims routing for affected sections follows the NYRx transition.

Each procedure code includes a frequency superscript (F1–F28) that defines dispensing limits; providers must use the frequency notation table to interpret limits for each code.

If a member exceeds an item's frequency limit, prior approval must be requested with supporting medical documentation explaining why the limit needs to be exceeded.

Items in Sections 4.1–5.0 are subject to the NYRx transition and are reimbursed through NYRx or DMEPOS FFS providers for MMC members after April 1, 2023; prior approval procedures remain in effect.

Coverage criteria for incontinence, catheterization, ostomy, and related supplies

Coverage criteria for intermittent catheters, diapers/liners/underpads, ostomy supplies, and related items include indication-specific rules, quantity limits, and documentation requirements.

Intermittent urinary catheters: straight tip catheters (A4351/A4295) are covered; coude tip catheters (A4352/A4296) are covered when the ordering practitioner documents treatment failure with straight tip catheters.

Intermittent urinary catheter with insertion supplies (A4353/A4297) is covered when the member requires intermittent catheterization outside the home setting or has documented recurrent UTIs while using standard intermittent catheters; otherwise prior approval is required.

Quantity limit for intermittent catheters: up to 200 total intermittent catheters (combination of catheters and catheters with supplies) per 30 days; claims exceeding this limit will be denied.

Age exclusion: diapers, liners, and underpads are not covered for children ≤3 years of age; medical records must support appropriateness of types and quantities for covered members.

Documentation requirement: fiscal orders must include a specific diagnosis code supported by clinical documentation in the member's medical record; claims without appropriate diagnosis will be denied and documentation must be available for Department review.

Diapers/underpads quantity limits: up to 250 disposable diapers/liners per 30 days (up to 8 changes/day); up to 5 reusable diapers per 30 days; up to 150 disposable underpads or up to 4 reusable underpads (2 bed, 2 chair) per 30 days. Reusable and disposable items of the same type may not be purchased in the same 30-day period.

Requests for quantities in excess of stated limits may be reviewed case-by-case through prior approval with supporting clinical documentation demonstrating a medical condition resulting in increased urine or stool output.

Dispenser responsibilities: maintain measurements (waist/hip, weight) and independent testing documentation that supports product sizing and compliance with DOH product specifications.

Transanal irrigation medical necessity criteria

Transanal irrigation systems may be considered medically necessary as part of bowel management when specific clinical criteria and contraindication exclusions are met.

Indication: chronic neurogenic bowel dysfunction in individuals aged 2 years or older with chronic fecal incontinence or constipation.

Prior therapy failure: initial management including diet changes, bowel habit training, laxatives or constipating medications must have failed.

Contraindications/exclusions: not appropriate for individuals with anal or colorectal stenosis, colorectal cancer, pelvic radiotherapy, recent abdomino-perineal surgery, active inflammatory bowel disease, diverticulitis, ischemic colitis, chronic/complex diverticular disease, recent abdominal/anal/colorectal surgery within 3 months, recent endoscopic polypectomy/colonic biopsy/mucosal resection/sub-mucosal dissection, severe autonomic dysreflexia, or during spinal cord shock phase.

Disposable glucometer coverage

Disposable glucometers are reimbursable under specific clinical situations; exclusions apply to backup devices and concurrent device/strip reimbursement.

ONE of: Dispensing is reimbursable when the ordering practitioner documents one of the following: newly diagnosed diabetes; gestational diabetes; Type 2 diabetes; medical need to change from a traditional to a disposable glucometer; emergency replacement while awaiting prior approval for a traditional glucometer.

If a disposable glucometer is dispensed, no additional test strips are reimbursable; Medicaid pays for either a traditional glucometer or a disposable glucometer but not both; disposable glucometers are not reimbursable as backup devices.

CGM coverage criteria and guidelines

Continuous glucose monitors (CGMs) and related supplies have defined clinical eligibility, dispensing pathway, and monitoring/documentation requirements.

Clinical eligibility: CGM may be covered for members with gestational diabetes, or members with type 1 or type 2 diabetes who are on an insulin treatment plan or insulin pump and who meet provider and monitoring criteria (ordered by endocrinologist or experienced enrolled Medicaid provider; compliant with regular visits to review CGM data).

Provider requirements: only providers who have had a visit with the patient within the last 6 months should order a CGM; prescribers must actively monitor and document CGM data and encourage diabetes education.

Dispensing pathway: certain CGMs and related supplies are on the Preferred Diabetic Supply Program (PDSP) and must be dispensed through a pharmacy provider; DMEPOS prior approval requests for PDSP items will be inactivated and referred to PDSP. Medtronic CGMs (E2102/A4238) remain authorized via DVS and billable by DMEPOS and pharmacy as specified.

Gloves coverage criteria

Glove reimbursement is limited to medically necessary use by the member or for sterile procedures; gloves included in kits or for caregiver PPE are not covered.

Gloves are reimbursable only when medically necessary for use by the member.

Sterile gloves are reimbursable only when medically necessary to perform a sterile procedure.

Gloves are not reimbursable as personal protective equipment for employees/caregivers, nor when included in a kit or tray (e.g., catheter or tracheostomy kits).

Medical supplies coverage entries (partial)

Selected medical supplies and billing notes (partial listing) are provided; detailed HCPCS entries and conditions are in the Coverage Guidelines and Fee Schedule.

Heat/Cold application items (E0210, E0215, A9273) are covered per their listed frequency designators; note that some items (ice cap/or collar) are not reimbursable.

Respiratory and tracheostomy supplies listed are for patient-owned equipment only; ventilator-dependent patients' supplies are included in the 30-day ventilator rental fee and certain items must not be billed with E0465/E0466.

Wound dressing categories (collagen, alginate/fiber gelling, foam, hydrocolloid, hydrogel, specialty absorptive, transparent film, gauze) are covered under listed HCPCS codes and sizes; see Fee Schedule for code-specific quantities and limits.

B4105 coverage criteria

The in-line digestive enzyme cartridge (B4105) is covered for enteral tube feeding when specific clinical requirements and manufacturer's use limits are met.

An established diagnosis of pancreatic insufficiency and/or fat malabsorption requiring fat hydrolyzation during enteral tube feeding is required.

Documented clinical symptoms of tube-feeding intolerance attributable to fat malabsorption (e.g., abdominal discomfort, bloating, cramping, increased flatulence, weight loss, steatorrhea) must be present.

Documented failure of, or contraindication to, standard pancreatic enzyme therapy and/or other treatment modalities must be shown prior to B4105 use.

Use must be during enteral tube feeding with a compatible formula and must follow the manufacturer's specifications without exceeding the daily maximum cartridge quantity.

Enteral formula and supply coverage

Enteral formulas and supply kits are covered for specific clinical populations and are billed in caloric units; daily and kit billing limits apply.

ELIGIBLE: Tube-fed individuals unable to chew or swallow who require enteral feeding (coverage up to 2500 calories/day).

ELIGIBLE: Individuals with rare inborn metabolic disorders requiring specific medical formulas (coverage up to 2500 calories/day); a qualifying ICD-10 diagnosis is required.

ELIGIBLE: Children under 21 when caloric and dietary nutrients cannot be absorbed or metabolized (coverage up to 2500 calories/day).

ELIGIBLE: Oral-fed persons with HIV/AIDS or related illness may receive supplemental nutrition when meeting BMI/weight-loss criteria and documented compliance (oral-fed supplemental limits apply).

Oral-fed supplemental nutrition limits: BMI <18.5 up to 1250 calories/day, or BMI <22 with documented unintentional weight loss ≥5% within prior 6 months up to 1250 calories/day; approved units are caloric units (calories per can / 100).

Enteral feeding supply kits (B4034–B4036) represent a daily supply fee; only one unit of service may be billed per day and kit contents must correspond to mode of administration.

Enteral nutritional therapy is not covered as a convenience food substitute or for standard milk-based infant formulas for oral-fed members; non-standard infant formulas are reimbursable under appropriate enteral therapy codes.

Nutrition and related supplies coverage criteria

Coverage criteria for enteral oral supplementation and parenteral nutrition include diagnostic, ordering provider, and billing cadence requirements.

Enteral oral supplementation eligibility: BMI <18.5 (up to 1250 kcal/day), or BMI <22 with documented unintentional weight loss ≥5% in prior 6 months (up to 1250 kcal/day); persons requiring total nutritional support due to permanent structural limitation preventing chewing when tube feeding is contraindicated may also qualify.

A qualifying ICD-10 diagnosis is required for inborn metabolic disorders; caloric units determine approved units (calories per can / 100).

Parenteral nutrition requirements: must be ordered by a physician who has seen the member within 30 days prior to ordering and documented inability to receive adequate nutrition orally or enterally; covered for GI conditions that impair digestion/absorption requiring IV feedings to sustain life (e.g., ischemic bowel, short bowel syndrome, intestinal fistula, obstruction, pancreatitis, GI cancer).

Prior approval: required for oral-fed persons with BMI over 18.5 in specified cases, persons with permanent structural limitation, or requests exceeding allowed daily caloric amounts; parenteral nutrition and supplies are billed weekly and quantity limits are maximum units per 7 days per the Fee Schedule.

Procedure Codes, Fee Changes, and Coding Notes

New and revised medical supply procedure codesHCPCSCovered

A4288	Valve for breast pump, replacement, each (By Report)
A4295	Intermittent urinary catheter; straight tip, hydrophilic coating, each ($1.51)
A4296	Intermittent urinary catheter; coude (curved) tip, hydrophilic coating, each ($4.55)
A4297	Intermittent urinary catheter; hydrophilic coating, with insertion supplies ($5.68)
A4351	Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, or silicone elastomer, etc.), each
A4352	Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, or silicone elastomer, etc.), each

New and revised DME supply codesHCPCSCovered

A4288	Valve for breast pump, replacement, each; listed with 'By Report' fee option
A4295	Intermittent urinary catheter; straight tip, hydrophilic coating, each — $1.51
A4296	Intermittent urinary catheter; coude tip, hydrophilic coating, each — $4.55
A4297	Intermittent urinary catheter; hydrophilic coating, with insertion supplies — $5.68
A4351	Intermittent urinary catheter; straight tip, with or without coating
A4352	Intermittent urinary catheter; coude tip, with or without coating

Fee changesHCPCSCovered

A4398

Ostomy irrigation supply; bag — fee changed from $1.01 to $15.76

Adhesive tape/remover codesHCPCSCovered

A4450	Tape, non-waterproof, per 18 square inches
A4452	Tape, waterproof, per 18 square inches
A4455	Adhesive remover or solvent, per ounce

AntisepticsHCPCSCovered

A4244	Alcohol or peroxide, per pint
A4245	Alcohol wipes, per box (100's)
A4246	Betadine or Phisohex solution, per pint

Breast pump and suppliesHCPCS

E0602	Manual breast pump
E0603	Standard electric breast pump
E0604	Hospital grade breast pump (rental only)
A4287	Disposable collection and storage bag for breast milk
A4288	Valve for breast pump, replacement

Canes and crutchesHCPCSCovered

A4635	Underarm pad, crutch, replacement, each
A4636	Replacement handgrip, cane, crutch or walker, each
A4637	Replacement tip, cane, crutch, or walker, each
E0100	Cane, includes canes of all materials
E0105	Cane, quad or three-prong
E0110	Crutches, forearm, pair
E0111	Crutch, forearm, each
E0112	Crutches, underarm, wood, pair

Incontinence productsHCPCS

T4521	Adult disposable incontinence product, brief/diaper, small
T4522	Adult disposable incontinence product, brief/diaper, medium
T4523	Adult disposable incontinence product, brief/diaper, large
T4524	Adult disposable incontinence product, brief/diaper, extra-large
T4529	Pediatric disposable incontinence product, small/medium
T4530	Pediatric disposable incontinence product, large
T4533	Youth disposable incontinence product
T4535	Disposable liner/shield/guard/pad/undergarment, each
T4537	Incontinence product, protective underpad, reusable, bed size
T4539	Incontinence product, diaper/brief, reusable

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Listed HCPCS codes for incontinence, catheterization, ostomy, and transanal irrigation suppliesHCPCSCovered

A4310	Insertion tray without drainage bag and without catheter (accessories only) each
A4311	Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating
A4314	Insertion tray with drainage bag with indwelling catheter, Foley type, two-way
A4320	Irrigation tray with bulb or piston syringe, any purpose each
A4322	Irrigation syringe, bulb or piston, each
A4326	Male external catheter with integral collection chamber, any type, each
A4335	Incontinence supply: miscellaneous
A4351	Intermittent urinary catheter; straight tip, with or without coating, each
A4352	Intermittent urinary catheter; coude tip, with or without coating, each
A4353	Intermittent urinary catheter, with insertion supplies, each

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Incontinence/ostomy suppliesHCPCSCovered

A4457	Enema tube, replacement only
A4458	Enema bag with tubing, reusable
A5105	Urinary suspensory with leg bag
A5112	Urinary leg bag; latex
A5113	Leg strap; latex, replacement
A5114	Leg strap; foam or fabric, replacement
A5120	Skin barrier, wipes or swabs (ostomy care only)
A5121	Skin barrier; solid, 6x6
A5122	Skin barrier; solid, 8x8
A5126	Adhesive or non-adhesive disc or foam pad

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Transanal irrigationHCPCSCovered

A4453	Rectal catheter for transanal irrigation
A4459	Manual transanal irrigation system

Commode accessoriesHCPCSCovered

E0160	Sitz type bath, portable
E0167	Pail or pan for commode chair, replacement
E0275	Bed pan, standard
E0276	Bed pan, fracture
E0325	Urinal; male, jug-type
E0326	Urinal; female, jug-type

Diabetic diagnostics and CGM suppliesHCPCSCovered

A4233	Replacement battery for home blood glucose monitor
A4234	Replacement battery, j cell
A4235	Replacement battery, lithium
A4250	Urine test strips (100)
A4252	Blood ketone test strip
A4253	Blood glucose test strips per 50
A4238	Supply allowance for adjunctive non-implanted CGM, 1 month
E2102	Adjunctive non-implanted CGM or receiver

Heat/Cold applicationHCPCSCovered

E0210	Electric heat pad, standard
E0215	Electric heat pad, moist
A9273	Hot water bottle, heat/cold wrap (ice cap/collar not reimbursable)

Family planning productsHCPCSCovered

A4266	Diaphragm for contraceptive use
A4267	Condom, male
A4268	Condom, female

GlovesHCPCSCovered

A4927	Gloves, non-sterile, per 100
A4930	Gloves, sterile, per pair

Heat/Cold applicationHCPCSCovered

E0210	Electric heat pad, standard
E0215	Electric heat pad, moist
A9273	Hot water bottle, ice cap or collar, heat and/or cold wrap (ice cap/or collar not reimbursable)

Mastectomy careHCPCSCovered

L8000	Breast prosthesis, mastectomy bra, without integrated breast prosthesis form
L8030	Breast prosthesis, silicone or equal, without integral adhesive
S8460	Camisole, post-mastectomy

ThermometersHCPCSCovered

A4931	Oral thermometer, reusable, any type
A4932	Rectal thermometer, reusable, any type

Wound dressings (multiple categories and sizes)HCPCSCovered

A6010	Collagen based wound filler, dry form, sterile, per gram
A6021	Collagen dressing, sterile, size 16 sq. in. or less
A6210	Foam dressing, wound cover, pad >16 ≤48 sq. in., without adhesive border
A6234	Hydrocolloid dressing, pad 16 sq. in. or less, without adhesive border
A6242	Hydrogel dressing, pad 16 sq. in. or less, without adhesive border
A6252	Specialty absorptive dressing, pad 16 sq. in. or less, without adhesive border
A6257	Transparent film, sterile, 16 sq. in. or less

Respiratory / Tracheostomy suppliesHCPCSCovered

A4605	Tracheal suction catheter, closed system
A4614	Peak expiratory flow meter, hand-held
A7003	Administration kit with small volume nonfiltered pneumatic nebulizer, disposable
A7013	Filter, disposable, used with aerosol compressor
A7501	Tracheostoma valve, including diaphragm
A7523	Tracheostomy shower protector

Wound care and bandage suppliesHCPCSCovered

A6256	Specialty absorptive dressing, wound cover, sterile, pad size more than 16 but <=48 sq in
A6257	Hydrogel dressing, wound cover, sterile, pad size more than 16 but <=48 sq in
A6402	Gauze, impregnated, other than water/saline/zinc paste, sterile, any width, per linear yard
A6448	Light compression bandage, elastic, knitted/woven, width less than 3 inches, per yard
A6550	Wound care set, for negative pressure wound therapy electrical pump

Enteral supplies and formulasHCPCSCovered

B4034	Enteral feeding supply kit; syringe fed, per day
B4035	Enteral feeding supply kit; pump fed, per day
B4087	Gastrostomy/jejunostomy tube, standard, each
B4149	Enteral formula, manufactured blenderized natural foods, 100 calories = 1 unit

Parenteral nutrition and hearing device battery HCPCSHCPCSCovered

B4185	Parenteral nutrition solution, per 10 grams lipids
B4187	Omegaven, 10g lipids
B4189	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, 10 to 51 grams of protein, premix
B4193	Parenteral nutrition solution, 52 to 73 grams of protein, premix
B4197	Parenteral nutrition solution, 74 to 100 grams of protein, premix
B4199	Parenteral nutrition solution, over 100 grams of protein, premix
B4220	Parenteral nutrition supply kit, premix, per day
B4224	Parenteral nutrition administration kit, per day
B5000	Parenteral nutrition solution, renal - premix
B5100	Parenteral nutrition solution, hepatic - premix

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Quantity per 30 days

Policy on fee-schedule quantitiesQuantities listed on the DME Fee Schedule for section 4.1 items are maximums per 30 days; prior approval is required to exceed these amounts.

ApplicabilityApplies to items listed in section 4.1 (medical/surgical supplies) on the DMEPOS Fee Schedule.

Exceeding limitsRequests to exceed the 30-day maximum must be submitted via prior approval with supporting clinical documentation.

Breast pump suction safety limit

Suction safety requirementBreast pump design must prevent suction greater than 250 mmHg.

Pump specification referenceStandard electric and manual pumps must include safety precautions to prevent suction >250 mmHg.

Operational criteriaPumps must provide adjustable suction pressure within the acceptable range (50–250 mmHg) and an automatic release mechanism for safety.

Replacement parts reimbursement exclusion window

Replacement parts reimbursement windowBreast pump replacement parts (A4288) are not separately reimbursable within six months of the initial pump purchase (E0602/E0603).

Condition for reimbursementReplacement parts reimbursable only when the part no longer functions properly (e.g., torn, warped, discolored).

Associated codesReplacement valve code: A4288 (valve for breast pump, replacement).

Quantity limits per 30 days

Disposable diapers/linersUp to 250 disposable diapers and/or liners per 30 days (covers up to eight changes/day).

Reusable diapersUp to 5 reusable diapers allowed per 30 days; reusable and disposable items of the same type cannot both be purchased within the same 30-day period.

Disposable underpadsUp to 150 disposable underpads per 30 days.

Reusable underpadsUp to 4 reusable underpads per 30 days (maximum 2 for beds and 2 for chairs).

Infusion set supply frequency

Infusion set supply frequencyEach infusion set for an external insulin pump (A4230/A4231/A4232) is considered a 60‑day supply.

CodesA4230 (non‑needle cannula type), A4231 (needle type), A4232 (syringe with needle for external insulin pump) noted as 60‑day supply.

Billing implicationDispensers should not bill more frequently than the 60‑day supply designation unless prior approval granted.

Enteral supply kit billing limit

Daily billing limitOnly one unit of service may be billed per day for enteral feeding supply kits (B4034–B4036).

Kit definitionSupply kits represent a daily supply fee and include all supplies necessary to administer the specific feeding type and maintain the feeding site (e.g., syringes, tubing, gauze, adapters).

Mode correspondenceDispensed supply kit must correspond to the mode of administration (syringe, pump, or gravity).

In-line enzyme cartridge use limit

Manufacturer daily maximumIn-line digestive enzyme cartridge (B4105) use must not exceed the manufacturer's specified daily maximum cartridge quantity.

Clinical indicationCartridge use limited to enteral tube feeding patients with pancreatic insufficiency/fat malabsorption and documented intolerance to standard therapy.

Documentation requirementUse must follow manufacturer specifications and be supported by clinical documentation of symptoms and prior treatment failure.

Enteral formula units (caloric units)

Caloric unit definitionEnteral formula units are billed in caloric units: 1 unit = 100 calories (calories per can ÷ 100).

Examples of codesB4149/B4150/B4152–B4159 are enteral formula codes with units defined per 100 calories.

Non‑standard infant formulaNon‑standard infant formulas are reimbursable under the appropriate enteral therapy code when indicated; units remain caloric units.

Parenteral nutrition quantity limit period

Billing cadence for parenteral nutritionParenteral nutrition and supplies are billed weekly; the Fee Schedule quantity limits are the maximum units allowed per 7 days.

ReferenceQuantity limits and maximum units per 7 days are specified on the Fee Schedule; billers must follow weekly billing cadence.

Prior authorizationPrior approval and clinical documentation may be required per parenteral coverage criteria (see guidance for ordering physician visit and indications).

Provider Requirements, Prior Authorization, and Billing Procedures

Prior Authorization

Where to request prior approval; see DMEPOS Policy Manual

Prior approval and prior authorization contacts and procedures are managed through the Bureau of Medical Review and OHIPMEDPA. Refer to the DMEPOS Policy Manual on eMedNY for definitions, participation requirements, and basis of payment, and direct prior approval questions to OHIPMEDPA@health.ny.gov.

DMEPOS Policy Manual available at eMedNY.org (DME Policy Section).
Prior Approval; Policies and Procedures concerning DMEPOS are managed via the Bureau of Medical Review/OHIPMEDPA.

Note

Meaning of code markers and authorization channels

Underlined procedure codes indicate that prior approval is required; codes preceded by '#' require authorization via the Dispensing Validation System (DVS); codes preceded by '*' require authorization via the IVR or Enteral Web Portal. When none of these markers apply, the code is a direct bill item.

'#' = authorization via DVS.
'*' = authorization via IVR or Enteral Web Portal (portal URL provided).
Underlined = prior approval required.

Prior Authorization

When to request prior approval and repair authorization

Request prior approval when quantity or frequency limits are exceeded. Repairs to patient‑owned devices requiring charges greater than 25% of the device price also require prior approval. Include medical documentation supporting the need for replacement/repair when submitting the PA.

Prior approval required when member exceeds item frequency limits (medical documentation must explain why).
Prior approval required for repairs when repair charge is greater than 25% of device price; repairs ≤25% do not require PA.

Prior Authorization

Prior approval for frequency exceptions

If a member needs an item more frequently than the listed frequency limit, the ordering practitioner must request prior approval and submit accompanying medical documentation explaining why the limit should be exceeded.

Frequency designators (F1–F28) define limits for each code; exceedance requires PA with clinical justification.

Documentation Required

Claims routing and authorization after NYRx transition

Items in Sections 4.1–5.0 are part of the NYRx transition; after April 1, 2023, claims for MMC members for those items are reimbursed through NYRx or via DMEPOS FFS providers and billed directly to Medicaid. All prior approval/authorization systems and procedures remain in effect as for current FFS members.

Post‑April 1, 2023 reimbursement routing: NYRx or DMEPOS FFS for sections 4.1–5.0.
Prior approval and authorization procedures continue to apply.

Prior Authorization

Prior approval pathway for excess quantities

Requests for quantities above the stated maximums (for example diapers, liners, underpads, or catheters) may be reviewed case‑by‑case via prior approval; submit supporting clinical documentation demonstrating a medical condition resulting in increased urine or stool output.

Excess quantity requests are subject to PA and clinical review.
Examples: limits cited (e.g., up to 250 disposable diapers/liners per 30 days) — requests above these limits need PA.

Denial Risk

Include specific diagnosis on fiscal order or risk denial

Fiscal orders for incontinence products must include a specific diagnosis code supported by clinical documentation in the member's medical record; claims submitted without an appropriate diagnosis will be denied.

The diagnosis on the fiscal order must be supported by clinical documentation and be available for Department review.
Disposable liners are not menstrual pads; personal hygiene products are not covered.

Prior Authorization

PDSP CGM dispensing via pharmacy; DMEPOS PA requests inactivated

Continuous glucose monitors and PDSP-listed supplies must be dispensed through a pharmacy provider per PDSP; DMEPOS prior approval requests for PDSP CGMs/supplies will be inactivated and referred to the PDSP. Medtronics CGMs remain authorized via DVS and billable by DMEPOS and pharmacy with HCPCS E2102 and A4238.

Effective June 3, 2024, PDSP CGMs/supplies (e.g., Dexcom, Freestyle Libre) only available via pharmacy.
DMEPOS PA requests for PDSP items will be inactivated and referred to PDSP.
Medtronics CGMs continue to use DVS authorization and HCPCS E2102/A4238 billing.

Billing Rule

Patient‑owned respiratory items and ventilator billing cautions

Respiratory/tracheostomy supplies are for patient‑owned equipment only; supplies for ventilator‑dependent patients are included in the 30‑day ventilator rental fee and must not be billed with E0465 or E0466.

Supplies/parts designated for patient‑owned respiratory equipment only.
If ventilator‑dependent, supplies are included in the 30‑day ventilator rental fee; do not bill in conjunction with E0465 or E0466.

Documentation Required

Definition of tracheostomy care kits (new vs established)

Tracheostomy care kits are defined separately for new and established tracheostomy care and include supplies such as tray, gloves, brush, gauze sponges, tracheostomy dressing, pipe cleaners, cotton tip applicators, twill tape, and tracheostomy tube holder.

New tracheostomy kit: includes necessary supplies for initial care (list above).
Established tracheostomy kit: includes similar supplies plus tube holder as applicable.

Prior Authorization

Use existing PA systems and DVS access for authorizations

Prior approval/authorization systems and DVS access remain in effect as for current FFS members. Providers should use DVS access where indicated (e.g., codes preceded by '#') and obtain prior approval for replacements or monitors when required.

A4221/A4224 supplies: providers access DVS once every 30 days for up to 4 units total per month (1 unit = 1 week).
Follow existing PA systems and DVS authorization procedures for codes marked '#'.
Replacement of monitors due to non‑warranty reasons requires prior approval.

Documentation Required

Order and documentation requirements for home blood pressure monitors

Home blood pressure monitors must be ordered by a qualified practitioner as part of a treatment plan requiring home blood pressure monitoring; replacement due to factors not covered by the manufacturer's warranty requires prior approval and documentation of use and compliance must be submitted with the request.

Order must be by qualified practitioner and tied to treatment plan.
Documentation of use and compliance required for replacement requests (PA needed if not covered by warranty).

Prior Authorization

Enteral formula prior authorization process and requirements

Prescribers must use the Enteral Web Portal or IVR to request prior authorization for enteral products and must send the signed fiscal order with the PA number to the dispenser. Dispensers activate the PA via the portal/IVR and submit correct billing codes; prior approval is required for oral‑fed persons with BMI over 18.5, persons with permanent structural limitation, or requests exceeding allowed daily caloric amounts.

Use Enteral Web Portal or IVR for PA requests and worksheets to prepare submissions.
Send signed fiscal order with documented PA number to dispenser; dispenser verifies and activates PA.
PA can be submitted electronically via ePACES or by mail (eMedNY‑361502).

Prior Authorization

Codes marked '*' require IVR or Enteral Web Portal PA

Procedure codes marked with an asterisk (*) require prior authorization through the Interactive Voice Response system (1‑866‑211‑1736) or the Enteral Web Portal (URL provided).

'*' = PA required via IVR (1‑866‑211‑1736) or Enteral Web Portal (https://medicaidenteralportal.health.ny.gov/portal/).

Documentation Required

Accepted PA submission methods (ePACES or paper form)

Prior approval requests can be submitted electronically via ePACES or by mail using the paper request form eMedNY‑361502; prescribers and dispensers should use the Enteral PA resources on the DME Manual homepage for instructions and worksheets.

Electronic submission: ePACES.
Paper submission: eMedNY‑361502 form.
Refer to ENTERAL PRIOR AUTHORIZATION (PA) RESOURCES on eMedNY for worksheets and coding guidance.

Note

DMEPOS Policy Manual — governing reference

Refer to the DMEPOS Policy Manual on eMedNY for definitions, provider participation requirements, and basis of payment; the manual is the governing reference for DMEPOS coverage, payment rules, and procedural details.

DMEPOS Policy Manual URL: eMedNY Provider Manuals DME Policy Section.
Manual contains definitions, participation requirements, and basis of payment.

Definitions, Frequency Codes, and Program Notes

Dispensing Validation System (DVS)

Dispensing Validation System (DVS)Items whose procedure code descriptions are preceded by a '#' require authorization via the Dispensing Validation System (DVS).

Authorization indicatorThe '#' symbol next to a procedure code denotes DVS authorization is required prior to dispensing.

Reference guidanceSee Purchases section and DME manual Policy Guidelines for additional DVS instructions.

Items requiring IVR/Enteral Web Portal authorization

IVR / Enteral Web Portal authorizationProcedure codes preceded by an asterisk (*) require authorization via the Interactive Voice Response (IVR) system or the Enteral Web Portal.

Procedure-code markingCodes marked with '*' in the fee schedule indicate IVR/portal prior authorization is required; portal URL and IVR contact provided in guidance.

PA submission methodsPrior approval requests for enteral products can be submitted electronically via ePACES or by mail using the eMedNY paper form; the prescribing practitioner must activate the PA through IVR/portal and send the signed fiscal order to the dispenser.

Frequency designators (F1–F28)

Frequency designators (F1–F28)Frequency designators F1–F28 define item dispensing limits (examples: F1=once/lifetime; F4=once/3 years; F16=once/6 months; F26=continuous monthly rental).

UsageEach procedure code includes a superscript frequency notation that indicates dispensing limits; exceeding limits requires prior approval with documentation.

Interpretation guidanceRefer to the Frequency table for exact meaning of each F‑code when determining allowable dispensing intervals.

MRA inclusion rule

MRA inclusion ruleCertain accessories/components are included in the base code's Maximum Reimbursement Amount (MRA) and are not separately reimbursable within 90 days of dispensing the base item.

Provider obligationIf an included accessory is required within 90 days of the base item, the equipment provider must supply it at no additional charge.

ScopeApplies to base equipment codes where accessories/components are specified as included in the MRA (e.g., wheelchairs, standers).

Diagnosis/documentation requirement; exclusions

Diagnosis/documentation requirementFiscal orders for incontinence products must include a specific diagnosis code supported by clinical documentation; claims without an appropriate diagnosis will be denied.

Non‑coverage of menstrual padsDisposable liners for incontinence are not menstrual pads; personal hygiene products such as menstrual pads are not covered.

Dispenser documentationDispenser must maintain measurements (waist/hip, weight) to support reimbursement for specific product type and size.

Age‑based exclusion under 3 years

Age exclusionDiapers, liners, and underpads are not covered for children age three years or younger (developmental incontinence considered normal).

RationaleCoverage excludes routine developmental incontinence for members ≤3 years of age.

ImplicationClaims for these items for children ≤3 years will be denied absent exceptional medical justification.

Preferred Diabetic Supply Program (PDSP) notes

PDSP dispensing channelCertain CGMs and related supplies listed on the Preferred Diabetic Supply Program (PDSP) must be dispensed through a pharmacy provider; DMEPOS providers cannot dispense PDSP items.

Effective datePDSP dispensing change effective June 3, 2024; PDSP items will be available only through pharmacy providers.

ExceptionMedtronics CGMs and related supplies are not currently on PDSP and continue to be authorized via DVS using codes E2102 and A4238.

Adjunctive CGM definition and implications

Adjunctive CGM definitionAdjunctive non‑implanted CGM (requires confirmatory fingerstick per device labeling) with supply allowance code A4238 and device code E2102 for receivers.

Supply allowanceA4238 represents a 1‑month supply unit for adjunctive CGM supplies (1 unit = 1 month).

Coverage noteCGM coverage requires provider oversight, recent visits, and documented monitoring per CGM coverage guidelines.

Patient‑owned equipment / tracheostomy notes

Patient‑owned equipment scopeSupplies and replacement parts listed for respiratory/tracheostomy items apply to patient‑owned equipment only.

Ventilator‑dependent noteIf the member is ventilator‑dependent, related supplies are included in the 30‑day ventilator rental fee and should not be billed separately with E0465/E0466.

Tracheostomy kit contentsTracheostomy care kits include tray, gloves, brush, gauze sponges, tracheostomy dressing, pipe cleaners, cotton tip applicators, twill tape, tracheostomy tube holder (lists differ for new vs established kits).

Tracheostomy care kit contents

Tracheostomy care kit definitionTracheostomy care kit (new and established) consists of tray, gloves, brush, gauze sponges, tracheostomy dressing, pipe cleaners, cotton tip applicators, 30' twill tape, tape, gauze roll, and tracheostomy tube holder.

Code examplesA4629 = Tracheostomy care kit for established tracheostomy; A4628 = cleaning brush; additional related codes listed in respiratory section.

Kit purposeKits include necessary supplies for routine tracheostomy care and are specified separately for new vs established kits.

Enteral feeding supply kit (B4034–B4036)

Enteral feeding supply kit definitionEnteral feeding supply kits (B4034–B4036) describe a daily supply fee that includes all supplies necessary to administer the feeding and maintain the feeding site.

Billing limitOnly one unit of service may be billed for any one day for B4034–B4036.

Included itemsKits may include syringes, measuring containers, tip adapters, anchoring devices, gauze pads, wipes, tape, feeding bags/containers, administration tubing, extension tubing, and tube cleaning brushes.

Unit defined as 100 calories for enteral formula billing

Enteral formula unitUnit defined as 100 calories for enteral formula billing (1 unit = 100 calories).

Caloric unit applicationUnits approved are caloric units determined by calories per can divided by 100; billing must use caloric units for B4149–B4159 codes.

Non‑standard infant formulaNon‑standard infant formulas are reimbursable under the appropriate enteral therapy code; units remain caloric units.

Caloric units billing explanation

Caloric unit billing explanationEnteral formula products are billed in caloric units: calculate units by dividing calories per can by 100; 1 unit = 100 calories.

Code examplesApplicable to B4149, B4150, B4152–B4159 and other enteral formula HCPCS codes which list '100 calories = 1 unit'.

Prior authorization noteSome enteral formulas are marked '*' and require prior authorization via IVR/Enteral Web Portal; prescribing practitioner must activate PA and submit signed fiscal order to dispenser.

Non‑standard infant formula reimbursement

Non‑standard infant formula coverageNon‑standard infant formulas are reimbursable under the appropriate enteral therapy code when clinically indicated.

Documentation requirementA qualifying ICD‑10 diagnosis is required for members with an inborn metabolic disorder to support coverage.

Unit measurementReimbursement uses caloric units (calories per can ÷ 100) regardless of standard or non‑standard formula status.

Policy Summary

Payerelderplan

PolicyMedical Supplies Procedure Codes & Coverage Guidelines

Policy CodePolicy N/A

Change TypeCodes & fee updatesquantity/frequency revisionsauthorization clarifications

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionRequest prior approval via the Bureau of Medical Review or IVR/Enteral Web Portal when quantity or frequency limits are exceeded and include supporting clinical documentation.

SourceLink

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