ModifiedFidelis CarePolicy N/A

Durable Medical Equipment, Prosthetics, and Orthotics procedure codes and coverage guidelines

Governance of procedure codes, fees, coverage guidelines, frequency/quantity, authorization types, and related billing/contact resources for New York State Medicaid DMEPOS providers.

Policy Summary

PayerFidelis Care

PolicyDurable Medical Equipment, Prosthetics, and Orthotics procedure codes and coverage guidelines

Policy CodePolicy N/A

Change TypeCode, fee, frequency and authorization updates

Effective DateN/A

Next Review DateN/A

Key ActionProviders must follow new authorization types and submit prior approval documentation where required (e.g., continuous oximeters, pediatric gait trainers, NPWT extensions).

SourceLink

POLICY UPDATE CHANGES

Procedure codes section updated with new/changed codes, descriptions, and fees (examples include A6519F7, E1032F6, LO720F4, L6028F3, L6029F3).

Criteria/Guidelines language changed for compression supports and external ambulatory infusion pump (Omnipod) coverage language.

Frequency/quantity entries changed for multiple L-codes (examples: L2820 from 1 unit to 2 units; several codes from once/year to twice/year).

Authorization types changed for numerous codes (examples: A4632 from Prior Approval to Direct Bill; many codes moved from Prior Approval to DVS).

Service area reassignment for A9999 from C-Orthotics and Prosthetics to E-DME.

multipleprocedure codes added/updated in this excerpt

frequency changesL-codes with updated frequency/quantity entries

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria and medical necessity

Selected coverage criteria and guideline changes

Updates to criteria and descriptions for specific code groups and items.

Compression supports criteria updated for codes A6519-46610 and related descriptions revised; changes include addition of custom fabricated wrap language and updated code descriptions (examples: A6519, A6584).

Wheelchair accessory descriptions standardized/updated for swingaway and headrest hardware (examples: E1032, E1033, E1034) and other accessory descriptions were revised.

Frequency and quantity limits updated for multiple L-codes and others (example: L2820 unit quantity increased from 1 to 2; several L-codes moved from once/year to twice/year).

Hospital beds and accessories coverage criteria

Covered when ALL of the following are met:

Hospital bed is covered when the member is bed-confined and requires body positioning not feasible in an ordinary bed, or requires attachments not usable on an ordinary bed; bed must be DME used in the home and FDA-listed/cleared.

ONE of (fixed/variable/semi-electric/total electric): E0251 (fixed height), E0256 (variable height), E0261 (semi-electric), and E0266 (total electric) are covered when the member meets the general hospital bed criteria and the device-specific criteria (e.g., head-of-bed elevation >30 degrees for CHF/CPD/aspiration after pillows/wedges ruled out; need for traction that can attach only to a hospital bed; need for different bed height for transfers; need for frequent position changes and independent operation).

ONE of (heavy/extraheavy/pediatric): Heavy/extra-heavy beds (E0301, E0302) covered when member weight exceeds code thresholds; pediatric enclosed beds (E0328) covered when general criteria plus behavior/cognitive risk, mobility risk, failed alternatives, and comprehensive monitoring plan are documented.

Accessories and components included in the MRA (maximum reimbursement amount) must be supplied at initial dispensing; no additional reimbursement within 90 days; if required within 90 days provider supplies at no additional charge.

When duration unknown, hospital beds and accessories should be rented; rental rules and repair/repair-authorization follow DME fee schedule and modifier guidance including -RR for rentals and -RB for replacement/repair of patient-owned devices; repairs >25% may require prior approval and fee schedule maximums apply.

Maximum units and frequency limits are governed by the DME Fee Schedule and frequency superscripts (F1–F26); prior approval required when limits exceeded.

Hospital bed coverage criteria

Hospital beds are covered when members meet specified functional, clinical, or weight-related criteria and alternatives have been considered.

Member meets one or more clinical positioning criteria: Member requires head-of-bed elevation >30 degrees most of the time for CHF, chronic pulmonary disease, or aspiration after pillows/wedges ruled out; or requires traction equipment attachable only to a hospital bed.

Device-specific need: Variable height bed (E0256) covered if member requires bed height different than fixed height to permit transfers; semi-electric (E0261) covered if requires frequent/urgent position changes and can operate controls; total electric (E0266) covered if meets variable-height and independent-adjustment requirements.

Weight or pediatric criteria: Heavy/extra-heavy beds (E0301/E0302) covered when member weight exceeds specified thresholds; pediatric enclosed bed (E0328) covered when criteria including cognitive/behavioral risk, mobility risk, failed less costly alternatives, and monitoring plan are documented.

Pressure reducing support surface coverage

Covered when ALL of the following are met:

Clinical conditions: Member is bedridden or wheelchair-bound and/or has documented decubitus where conventional cushioning has failed.

Group 1 criteria: Completely immobile or limited mobility plus any stage pressure ulcer on trunk or pelvis and one or more risk factors (impaired nutrition, incontinence, altered sensory perception, compromised circulation).

Group 2 criteria: Multiple Stage II ulcers despite use of Group 1 surface for ≥1 month, or large/multiple Stage III/IV ulcers, or recent flap/graft surgery with prior Group 2 surface use; air-fluidized beds not covered at home.

Oxygen therapy coverage and documentation

Covered when ALL of the following are met:

Practitioner must order oxygen in writing and document severe lung disease or hypoxia-related symptoms; oxygen therapy must be integral to a treatment plan and alternatives considered clinically ineffective.

Oxygen thresholds: Coverage thresholds include arterial PaO2 ≤55 mm Hg or SpO2 ≤88% at rest (awake); specific sleep and exertional thresholds apply and PO2 56–59 mm Hg/SpO2 89% may qualify with cor pulmonale, pulmonary hypertension, erythrocytosis or dependent edema.

Liquid oxygen covered only if member requires constant flow >5 LPM or must be away from home long periods; members qualifying for liquid oxygen cannot receive other delivery systems concurrently.

Home oxygen services reimbursed on an all-inclusive 30-day rental rate; spot-check pulse oximeter included in monthly rental and not billable separately; portable oxygen concentrator (E1392) is not reimbursable with other oxygen system codes.

Oximeter coverage and limits

Covered when ALL of the following are met:

Spot-check (intermittent) oximeters are included in the monthly oxygen rental and must not be billed separately.

Continuous oximeters (for monitoring, trending, alarms) require prior approval; short-term (<6 months) are rented and rental fees apply toward purchase if later purchased; long-term (>6 months) may be purchased with supplies requiring approval.

Approval for continuous oximeter requires documentation: diagnosis/medical condition, current oxygen orders, treatment plan with parameters and interventions, and caregiver availability/training.

Pulse oximeter probe limits: disposable probes limited to 4 per month; reusable probes limited to 1 per 12 months; prior approval required for probes for member-owned equipment.

Ventilator coverage and included services

Covered when ALL of the following are met:

Home ventilators (E0465–E0468) are covered for neuromuscular disorders, thoracic restrictive disorders, or chronic respiratory failure when documented in the medical record.

Medical record must document the underlying condition, the need for ventilator support, frequency of use, and ventilator settings on the fiscal order.

Only one ventilator code reimbursable per rental month; ventilators are not covered when used only as CPAP or BiPAP; certain ventilator and BiPAP ST codes are not to be billed in combination.

E0467/E0468 functionality includes oxygen, nebulizers, suction, cough stimulator, MI-E, HFCWO, oscillatory PEP devices and related accessories which will not be separately reimbursable; 30‑day rental fee includes delivery, maintenance, repair, parts, supplies and back-up equipment.

Ventilators and respiratory device coverage criteria

Conditions and documentation required for coverage of ventilators, PAP devices, and airway clearance equipment:

Ventilators are covered for neuromuscular disease, thoracic restrictive disorders, and chronic respiratory failure when supported by documentation in the member's medical record.

Providers must document underlying diagnosis, ordering practitioner rationale, frequency of use, and ventilator settings on the fiscal order; providers are responsible for maintaining documentation meeting coverage criteria.

Exclusions/billing limits: Home ventilators not covered when used solely as CPAP (E0601) or BiPAP (E0470); E0465/E0466 and BiPAP ST devices are not to be billed in combination and only one ventilator code reimbursable per rental month.

CPAP (E0601) covered for OSA when facility polysomnogram or eligible HSAT demonstrates AHI/RDI thresholds and symptom/comorbidity documentation; CPAP replacement before/after 5‑year useful life requires in-person evaluation and objective adherence evidence (≥4 hrs/night on ≥70% nights over a consecutive 30‑day period within last 6 months).

Pediatric gait trainer coverage

Pediatric gait trainers are covered when ALL of the following are met:

Member unable to stand or ambulate independently due to neuromuscular, congenital, or similar disorders causing severe motor and balance dysfunction.

Member's lower extremity alignment can tolerate upright standing; member does not have orthostatic hypotension, POTS, osteogenesis imperfecta, osteoporosis, or other brittle bone disease.

Member demonstrated improved mobility/function or maintained ambulation with the requested trainer during a trial; a home ambulation/therapy plan is provided and caregiver training/availability documented.

Clinical documentation from a trial period (make/model, trial length, results), prescription, and detailed letter of medical necessity must be submitted with prior approval request; HCPCS codes include accessories/components.

Provision of both a standing system and a walker/gait trainer is typically considered duplication; member must not require both concurrently unless justified.

Wheeled mobility equipment coverage

Wheeled mobility equipment (WME) covered when ALL of the following are met:

Member has a mobility limitation that significantly impairs ability to perform one or more mobility-related activities of daily living (MRADLs).

Limitation cannot be sufficiently resolved by an appropriately fitted cane or walker; least costly medically appropriate alternatives considered for payment determination.

Evaluation by a qualified practitioner experienced in wheelchair evaluation is required; practitioner must document medical necessity and have no financial relationship with the supplier; documentation must include functional assessment, history, physical findings, plan of care, and list of current WME/SPC with make/model and rationale.

Prior to or at delivery an on-site home evaluation is required to verify maneuverability, storage and safe use; supplier must maintain original signed written order prior to delivery and detailed justification for equipment selection.

If coverage criteria are not met, payment is based on least costly medically appropriate alternative considering weight, seating needs, amount/type of use and other features.

Manual Wheelchair Coverage Criteria

Manual wheelchairs are covered when ALL of the following are met:

Member has a mobility limitation that significantly impairs participation in one or more MRADLs and the limitation cannot be sufficiently resolved with an appropriately fitted cane or walker.

Use of a manual wheelchair will significantly improve participation in MRADLs and the member will use it regularly; the member has sufficient upper/lower extremity function to self-propel or has a caregiver available to provide assistance as needed.

Reimbursement for a new manual wheelchair includes standard parts (armrests, seat, leg rests, footrests, belts, tires, brakes, side guards, attendant handles); these parts are not billed separately with a new wheelchair.

Device-specific: Coverage conditions for tilt-in-space, pediatric sizing, ultra-lightweight, heavy-duty, and custom-made wheelchairs require meeting additional device-specific criteria and documentation per code descriptions.

Back-up Manual Wheelchair

Back-up manual wheelchairs covered when ALL of the following are met:

Member meets criteria for a power mobility device (primary mobility) and meets criteria for a rented or purchased back-up manual wheelchair.

Member is unable to complete MRADLs without a back-up manual wheelchair and the back-up accommodates the seating/positioning components (SPC) on the primary wheelchair; if SPC cannot be transferred, secondary seating documentation (make/model and manufacturer statement) required.

Ultra-lightweight wheelchairs should not be dispensed as back-up manual wheelchairs unless required dimensions are not available in less costly alternatives.

Powered Mobility Devices, POVs, and Power Wheelchairs

PMDs, POVs and PWCs covered when ALL of the following base PMD criteria are met plus device-specific requirements:

Member has a mobility limitation that impairs participation in one or more MRADLs, the limitation cannot be sufficiently and safely resolved using an appropriately fitted cane or walker, and the member lacks sufficient upper extremity function to self-propel an optimally configured manual wheelchair.

POV-specific: POVs (4‑wheeled with tiller steering) require safe transfers, ability to operate tiller, postural stability in standard seating, adequate home access and storage, appropriate weight capacity, and willingness to use; Group 2 POV added capabilities must be medically justified or payment based on least costly Group 1 POV.

PWC-specific: Power wheelchairs are covered when PMD criteria met but POV criteria 4–6 are not met, plus additional PWC criteria: member can safely and independently operate PWC, home/community access adequate, weight within capacity, and not unwilling to use PWC.

Reimbursement for POV includes batteries, charger, seating, controller, tiller steering and tires and these parts may not be billed separately with a new POV.

General PWC coverage criteria

General PWC coverage requirements (members must meet ALL of the following):

Member meets basic PMD coverage criteria 1–3 and does not meet POV coverage criteria 4–6 (i.e., cannot safely use a POV), and meets PWC-specific criteria 10–13.

Member has the mental and physical ability to safely and independently operate the provided power wheelchair; home/community environments provide adequate access and maneuvering space.

Member's weight is less than or equal to the wheelchair weight capacity and member has not expressed unwillingness to use a power wheelchair.

Power option specific coverage

Power option coverage varies by group and requires documentation; covered when ALL applicable criteria are met:

No power option: No-power option devices (Group-specific) are covered when device features and non-expandable controller limitations meet group criteria and clinical needs.

Single power option covered when Group-specific single power option criteria and general PWC criteria are met (device accepts/operates only one power option at a time).

Multiple power options covered when member meets PWC criteria and either requires tilt+recline medical need or uses a wheelchair-mounted ventilator; expandable controller and capability to accommodate more than one powered seating system required.

Justification for multiple power options must document medical necessity for each option (e.g., medical need for tilt/recline or ventilator mounted to wheelchair).

Included accessories and billing rules

Included accessories and billing rules (apply to ALL PWCs):

Reimbursement for new PWCs includes batteries, charger, complete set of tires and casters, footrests or foot platform, non‑elevating leg rests, standard proportional joystick (MRA includes joystick), fixed/non-adjustable armrests, joystick hardware, belt/safety belt and attendant handles; these items are not billed separately with a new power wheelchair.

Separately billable items: Angle adjustable footplates, adjustable height armrests, and elevating leg rests may be billed separately for Groups 3 and 4 or as specified in group rules; when alternate drive control provided on a new PWC attendant control joystick is not separately payable.

Group feature criteria

Each PWC group has required physical and performance features (member/device must meet ALL applicable group features):

Group 1 features: Standard duty ≤300 lb; length ≤40 in; width ≤24 in; min speed 3 mph; range 5 miles; obstacle climb 20 mm; specified fatigue/drop tests; non-expandable controller; portable limits.

Group 2 features: Length ≤48 in; width ≤34 in; min speed 3 mph; accommodates seating/positioning items (except captain's chairs); may have non-expandable controller or single power option variants.

Group 3 features: Higher performance: min speed 4.5 mph; range 12 miles; obstacle climb 60 mm; drive wheel suspension; intended for neurological/myopathy/congenital conditions; supports heavier capacities and upgradeable controllers.

Group 4 features: Highest performance (greater speed/range/obstacle capabilities) and accommodates advanced seating/positioning components; group-specific limits govern coverage.

Coverage criteria for PWCs, power options, SPCs, and power assist

Coverage for PWCs, power options, SPCs, and power assist requires ALL applicable criteria be met:

Device coverage requires meeting group-specific criteria (Groups 3–5 features/limits) and the general PWC coverage criteria (PMD criteria 1–3 and PWC 10–13).

Single power option coverage requires meeting group-specific single power option criteria plus general PWC criteria.

Multiple power options require expandable controller at initial issue, accommodation for more than one powered seating system and/or ventilator mounting capability; medical justification for multiple options must be provided.

SPCs are covered when member meets WME criteria, SPC meets quality/coding definitions, primary and back-up WME bases accommodate the SPC, and code-specific coverage criteria are met.

Power assist (E0986) covered only when PWC coverage criteria are met and documentation includes a thorough upper extremity assessment, a detailed successful trial in customary environments, justification versus a power wheelchair, and absence of excessive spasticity or uncontrolled seizures.

Coverage for power seating components (tilt and recline)

Power seating components (tilt and recline) are covered when ALL of the following are met:

Member meets Seating and Positioning Component (SPC) coverage criteria 1–3 and the coverage criteria for the equivalent manual function (tilt or recline).

Member has the mental and physical ability to safely and independently operate the provided power tilt and/or recline function.

Combination functions: Combination tilt and recline are covered when the member meets criteria for both components and one function alone would not meet seating/positioning needs.

Coverage for reclining backs

Reclining backs covered when ALL of the following are met:

Member meets SPC coverage criteria 1–3 and has a plan of care requiring recline to complete MRADLs.

Recline levels: Manual semi-reclining backs (recline >15° and <80°, e.g., E1225) and fully reclining backs (>80°, e.g., E1226) are covered when positioning needs cannot be met by upright/fixed-angle chairs and postural control or intermittent catheterization requirements justify recline.

Power seat elevation (E2298) coverage

Power seat elevation (E2298) covered when ALL of the following are met:

E2298 is limited to complex power wheelchair bases (K0835–K0898) except rare circumstances; selection must be medically necessary and not solely for caregiver convenience.

Member meets PMD coverage criteria 1–3 and has demonstrated mental and physical ability to safely and independently operate the power seat elevation function.

Invoice required when billed as cost+51%; cost+51% pricing will not exceed the DMEPOS Fee Schedule cap.

Power standing system coverage and documentation

Power standing systems (E2301) are covered only when ALL of the following are met and documented:

Wheelchair evaluation and recommendations by a qualified physician, PT or OT experienced in complex rehab wheelchair prescription and a written LOMN are submitted.

Member has a physician‑recommended standing program, adequate cognition and safety awareness, and cannot access a static home standing system after documented trial of less costly alternatives.

Exclusions: Member must not have orthostatic hypotension, POTS, brittle bone disease (e.g., osteogenesis imperfecta), or hip/knee flexion contractures >45°; documentation of bone loss or contracture risk required when applicable.

Prior authorization requires fiscal order and LOMN including comprehensive history/physical, wheelchair evaluation, trial documentation of alternatives, home therapy plan, caregiver availability and itemized DME list.

Seat cushion coverage (E2601, E2603, E2604)

Seat cushions covered when ALL applicable SPC criteria are met:

General use seat cushions (E2601) covered when SPC guideline criteria 1–3 are met.

Skin protection cushions (E2603/E2604) covered when SPC criteria met and member has current or past pressure ulcer on seating area, impaired sensation from specified neurologic diagnoses, inability to perform functional weight shift, or is confined to wheelchair >4 continuous hours/day.

Positioning cushions (E2605 etc.) covered when SPC criteria met and member has significant postural asymmetries or specified diagnoses (e.g., hemiplegia, muscular dystrophy).

Control interfaces, batteries, and replacement components

Control interfaces, batteries, and replacement drive components covered when medically necessary or replacement required:

Electronic control interfaces and specialty input devices (E2310–E2333 series), head/chin controls, sip‑and‑puff, and related interfaces are covered when clinically indicated and properly documented.

Batteries and chargers (E2358–E2371 series) and replacement drive motors/gearboxes (E2368–E2370) are covered as replacement-only codes when necessary for operation.

Replacement-only codes for tires, wheels, forks and other components (E2381–E2396 etc.) are used for maintenance and replacement as clinically required.

Dynamic positioning hardware

Dynamic positioning hardware (E2398) covered when ALL criteria are met:

Member has moderate to severe hypertonicity or documented history of rocking/shaking related to behavior or increased muscle tone.

There is documented evidence of frequent backrest/back canes or wheelchair frame repairs due to the member's behaviors or tone.

Coverage requires meeting both the movement/behavior criterion and the repair‑frequency criterion with supporting documentation.

Seating and positioning cushions and backs

Seating and positioning cushions and backs covered when SPC guidelines and additional diagnostic/functional criteria are met:

SPC coverage requires meeting SPC guideline criteria 1–3 and code‑specific coverage criteria; primary and back‑up bases must accommodate SPC.

Skin protection cushions/back: Covered when member has current/past pressure ulcer on seating area, absent/impaired sensation due to listed neurologic diagnoses, inability to perform functional weight shift, or is confined to wheelchair >4 continuous hours/day, with supporting evaluation and measurements.

Positioning cushions/backs: Covered when significant postural asymmetries or specified diagnoses are present and a licensed independent clinician documents standard systems insufficient; custom fabricated cushions/backs require comprehensive evaluation.

Accessories and dynamic components

Accessories and dynamic components covered when ALL of the following are met:

Padding/positioning blocks: Covered when documented skin breakdown or need to stabilize upper extremities due to strong spasticity exists and less costly alternatives tried and failed; may be provided with UESS or mounted to WME when UESS criteria not met.

Dynamic foot supports/shock absorbers: Covered when member has moderate to severe hypertonicity, less costly alternatives have failed, and documentation/trial demonstrates benefit or frequent repairs without them.

Miscellaneous DME and device-specific rules

Miscellaneous DME and device-specific rules (key limits and rental policies):

Infusion pump rental caps apply: maximum monthly rental for specified pumps (B9004, B9006, E0781, E0791) is $60.60; short‑term daily maximum $5.00 up to monthly cap.

Paraffin bath units covered for RA with documented medication treatment failure when ordered by rheumatologist; hospital‑grade breast pumps have DVS authorization up to 2 months, >2 months requires prior approval.

Apnea monitors: children <1 year require electronic DVS prior authorization ordered by board‑certified pulmonologist/neonatologist; members >1 year require prior approval; devices rented with monthly fees including maintenance and accessories.

Seat lift mechanisms for patient‑owned furniture covered only when separate mechanism prescribed as part of physician's course of treatment, member meets strict functional criteria (severe hip/knee arthritis or severe neuromuscular disease, completely incapable of standing from a regular chair), other therapies tried/failed, and member able to ambulate once standing; excluded devices that catapult the member to standing and not billable with patient lift codes.

Seat lift mechanism coverage

Seat lift mechanisms for patient‑owned furniture are covered when ALL of the following are met:

Device must be a separate seat lift mechanism (not integrated into furniture) and prescribed as part of physician's course of treatment to improve or arrest deterioration.

Member must have severe hip or knee arthritis or severe neuromuscular disease and be completely incapable of standing from a regular armchair in the home; difficulty alone is insufficient.

Covered devices must operate smoothly, be controllable by the member, assist standing/sitting without other assistance, and once standing the member must be able to ambulate.

Exclusions: Excluded: spring‑release/catapult‑type lifts; patient lift (E0630) and seat lift equipment (E0627/E0629) are not to be billed in combination.

Special needs bed

Special needs bed coverage and coding guidance:

Special needs beds that do not meet hospital bed code descriptions should be submitted under miscellaneous code E1399; features include fixed foundation, electric adjustability, side rails >24 in, or integrated full enclosure.

Fully enclosed special needs bed covered when hospital bed pediatric criteria (10–15) are met and documentation includes medical justification for each accessory, exploration of less costly comparable beds, and supporting monitoring plan; only twin size considered unless manufacturer lacks twin option.

Positioning bath chairs, shower/commode chairs

Positioning bath chairs and shower/commode chairs covered when ALL of the following are met:

Positioning bath chair covered when documented medical and hygiene needs require stable positioning/support during bathing; MRA includes necessary positioning accessories (head support, trunk laterals, hip laterals, belts).

To obtain prior approval for positioning bath chairs and stand additions, code E1399 must be used and submitted with a valid order and manufacturer's quote on a single prior approval line; prior approval priced up to established MRA.

Reclining shower/commode chair covered when recline necessary to complete hygiene or postural control; reimbursement via E1399.

Rehab self‑propelling shower/commode chair: Covered when member has roll‑in shower access and can independently self‑propel and complete shower routine.

Toilet systems coverage

Toilet systems covered when ALL of the following are documented:

Documentation from a Urologist or Neurologist that the member is physiologically capable of toilet training, evidence of success with an established toilet training program, and inability to use a standard toilet due to physical limitations requiring additional support.

Standers (including mobile and multi-position)

Standers (including mobile and multi‑position) are covered when ALL of the following are met:

Member unable to stand or ambulate independently due to neuromuscular, congenital, or acquired skeletal conditions and at high risk for lower extremity contractures not manageable by other modalities.

Member's lower extremity alignment allows tolerance of upright position; excluded diagnoses include orthostatic hypotension, POTS, brittle bone diseases, or hip/knee flexion contractures >45°.

Member has demonstrated improved mobility/function or maintained status with use of requested stander during trial and can follow a home standing program; provision of walker/gait trainer with stander typically considered duplication of service.

Prior approval required for adults (standing frame/table system codes ages 21+) with documentation including prescription, detailed LOMN, comprehensive H&P, failure of less costly alternatives (make/model and trial lengths), home therapy plan, caregiver availability, and itemized accessories.

Pneumatic Compression Devices (E0650/E0651/E0652)

Pneumatic compression devices (PCDs) and lymphedema/CVI coverage criteria (ALL required as specified):

PCDs (E0650/E0651/E0652) covered only after all less invasive treatments attempted and unsuccessful; member must have diagnosis supporting device use.

Lymphedema prerequisites: For lymphedema: documented diagnosis plus marked hyperkeratosis/hyperplasia/pigmentation or papillomatosis/deformity/skin breakdown with lymphorrhea; documented 4‑week conservative therapy trial demonstrating failed response including measurements, compliance with compression (minimum 30 mmHg distally), exercise and elevation; evidence of participation in MLD program.

CVI prerequisites: For CVI: edema in affected limb, one or more venous stasis ulcers, and non‑healing ulcers after a six‑month trial of conservative therapy (which includes the 4‑week lymphedema trial criteria plus appropriate wound care).

E0652 specifics: E0652 (segmental with calibrated gradient) covered when E0650/E0651 criteria met, MLD/self‑MLD ≥30 min/day, lymphedema extends to chest/trunk/abdomen beyond standard sleeve limits and failed 4‑week trial, and diet/anemia/medication optimization attempted; appropriate appliance codes must accompany compressor code.

E0652 pneumatic compression (lymphedema involving chest/trunk/abdomen)

E0652 coverage (lymphedema extending to chest/trunk/abdomen) requires ALL of the following:

Diagnosis of lymphedema extending onto chest/trunk/abdomen and coverage criteria for E0650/E0651 are met.

Manual lymph drainage (MLD) and self‑MLD performed at least 30 minutes per day and documented compliance.

Lymphedema extends beyond limits of standard compression sleeves and failed to improve with a 4‑week trial that meets lymphedema trial requirements; diet evaluation and correction of anemia/hyponatremia and medications optimized as appropriate.

Appliance codes appropriate to the compressor model are specified with the prior approval request.

Tumor Treatment Field Therapy (E0766) for newly diagnosed GBM

Tumor Treatment Field Therapy (E0766) coverage — all criteria must be met:

Histologically confirmed WHO grade IV astrocytoma (newly diagnosed GBM).

Initial treatment with maximal debulking surgery followed by chemotherapy and radiotherapy, and TTFT initiated within 7 weeks of last concurrent chemo/radiotherapy dose.

Karnofsky Performance Score ≥70, no evidence of progression by RANO criteria, patient ≥22 years, non‑pregnant (if applicable), and absence of intracranial shunt or other implanted intracranial device.

Patient will use TTFT for an average of 18 hours per day; initial prior approval granted for 3 months; continued coverage requires re‑evaluation between day 60 and 91 documenting clinical benefit and adherence.

Topical Oxygen Wound Therapy (A4575 with E1390)

Topical Oxygen Wound Therapy (A4575 with E1390) covered when ALL of the following are met:

A complete wound therapy program appropriate to the wound type has been attempted and documented (evaluation, dressing management, debridement if present, nutritional evaluation, wound measurements, and other wound care measures).

Wound types: One or more of these: Stage IV pressure ulcers; neuropathic (diabetic) ulcers with comprehensive diabetic management; venous insufficiency ulcers with compression/elevation; non‑healing surgical/traumatic wounds needing accelerated granulation; chronic ulcers ≥30 days of mixed etiology.

Documentation must include prior treatments, wound measurements, exudate, granulation/necrosis, and training; initial electronic prior authorization (DVS) for A4575 granted up to 16 days in a 28‑day period (4 days on/3 days off schedule); prior approval required beyond 4 weeks and detailed weekly measurements required for extensions.

TOWT not covered for wounds with necrotic tissue if debridement not attempted, untreated osteomyelitis near wound, cancer in wound, fistula to organ/cavity near wound, or Stage I–III pressure ulcers.

Negative Pressure Wound Therapy (NPWT)

Negative Pressure Wound Therapy (NPWT) coverage — all applicable criteria:

E2402 billed as monthly recurring rental; supplies (A6550 wound care set, A7000 canister) billed separately.

NPWT is covered for chronic Stage IV pressure ulcers, neuropathic ulcers, venous/arterial insufficiency ulcers, non‑healing surgical/traumatic wounds, or chronic ulcers ≥30 days after a complete wound therapy program has been attempted; initial 30 days authorized without prior approval; prior approval required for extension beyond 30 days.

Documentation should show prior complete wound therapy attempts, hospital/facility trial of NPWT prior to home when applicable, evidence of compliance, and availability of licensed personnel for dressing changes; extension requests require documentation of wound healing metrics and compliance.

Infusion pumps and insulin pumps

Infusion and insulin pumps covered when ALL of the following are met:

Therapy and prescribed pump must be appropriate for home use and adequate physician supervision specified on the prescription.

Insulin pump specific: For external ambulatory insulin pump (E0784): member must have been on multiple daily injections for ≥6 months with documented failure to achieve control (not explained by noncompliance), meet glycemic criteria (e.g., HbA1c >7%, recurrent hypoglycemia, wide glucose fluctuations, dawn phenomenon), and have completed comprehensive diabetes education.

Preferred Diabetic Supply Program covers disposable pump supplies (e.g., Omnipod) under pharmacy program; provider must follow program guidance for supplies coverage.

SGD upgrade, repair and reimbursement criteria

Speech‑generating devices (SGDs) upgrade, repair and replacement criteria — ALL required for coverage:

Upgrade/replacement covered only when current device is no longer clinically effective; documentation must state why device fails to meet functional communication needs and describe significant changes in abilities or environment justifying replacement (not due to technology advances alone).

Repair requests must include manufacturer quote for repair cost; when damage due to trauma include SLP or physician statement on cause and prevention; decision to repair vs replace based on cost‑effectiveness.

Reimbursement for a new SGD includes screen protectors, batteries, power components, software, stands (not mounts), and carrying case; accessory billing follows code guidance.

Positioning car seats and FES devices

Positioning car seats and FES device coverage notes — covered when ALL of the following are met:

Member's postural needs cannot be safely met by less costly alternatives; size or postural support needs restrict use of standard car seats; seat is used in primary caregiver's personal vehicle.

Reimbursement includes head support, trunk pads, harnesses, abductor pommel, wedges, tilt/recline and LATCH/tether straps; additional medically necessary accessories require prior approval under E1399.

FES devices considered when qualifying devices are submitted for prior approval billed using E1399; replacement accessories billed only for covered FES devices.

Repair billing and warranty rules

Repair billing and warranty rules — follow ALL of the following:

Repairs and parts covered under manufacturer's warranty must not be billed to Medicaid; when labor is performed by manufacturer Medicaid pays provider per manufacturer's invoice with itemized labor/parts.

For replacement parts with specific HCPCS codes report part code and K0739 for labor; for replacement parts to base equipment report base code with -RB modifier and K0739 for labor; for miscellaneous parts use E1399/K0108/A9900 with -RB and K0739 for labor.

Repair prior approval submissions must include specific parts requested with cost quotes/invoices, list of other repairs not requiring prior approval, anticipated useful life; if device not originally NYS‑funded include serial number, date provided, funding source and original documentation; K0739 labor fee $18 per 15 minutes with >2 hours requiring prior approval.

Cranial remolding orthosis (S1040) criteria

Cranial remolding orthosis (S1040) coverage — ALL of the following must be satisfied:

Member has moderate to severe positional head deformity associated with prematurity, restrictive intrauterine positioning, cervical abnormalities, birth trauma, torticollis and/or sleeping positions; anthropometric measurements verify moderate to severe plagiocephaly documented by a physician experienced in such measurements.

Member age between 3 and 18 months with reasonable likelihood of continued skull growth.

Documentation of at minimum a 2‑month conservative trial of repositioning and stretching exercises (alternating back/side sleeping, supervised tummy time, rearranging crib relative to light source, limiting supine time, limiting time in strollers/carriers/swings, neck motion exercises) prior to consideration.

Valid fiscal order signed by pediatrician/general surgeon with pediatric specialty or craniofacial surgeon and documentation of medical necessity from pediatric neurosurgeon or craniofacial surgeon accompanying prior approval.

Cranial remolding orthosis (helmet) coverage criteria

Cranial remolding orthosis is covered when ALL of the following are met:

Diagnosis: moderate to severe positional head deformity/plagiocephaly confirmed.

Anthropometrics: documented anthropometric measurements by an experienced physician verifying moderate to severe plagiocephaly.

Age: patient age between 3 and 18 months at time of treatment with reasonable likelihood of continued skull growth.

Conservative therapy: documented minimum 2‑month trial of repositioning and stretching exercises as outlined in policy prior to orthosis consideration.

Ordering provider: Valid fiscal order signed by a pediatrician, general surgeon with pediatric specialty, or craniofacial surgeon; specialty documentation of medical necessity from pediatric neurosurgeon or craniofacial surgeon required.

Spinal orthoses (TLSO/CTLSO/Lumbar) coverage criteria

Spinal orthoses (TLSO/CTLSO/Lumbar) are covered when ONE or more of the following indications are met:

To reduce pain by restricting trunk mobility.

To facilitate healing following a spine injury or surgical procedure to the spine or related soft tissues.

To support weak spinal muscles and/or spinal deformity.

Device type must match appropriate HCPCS/L‑codes listed in coverage and fitting/customization documented (prefabricated trimmed/modified or custom fabricated as indicated).

HCPCS/L-code updates, fee schedule and frequency rules

Selected updated/added codes and descriptionsHCPCSCovered

A6519F7	Gradient compression garment; not otherwise specified, for nighttime use, each
E1032F6	Wheelchair accessory, manual swingaway, retractable or removable mounting
LO720F4	Cervical-thoracic-lumbar-sacral-orthoses (CTLSO), prefabricated item customized to patient
L6028F3	Partial hand including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model
L6Z0QF3	Upper extremity addition, external powered feature, myoelectronic control module

example covered HCPCS and special codesHCPCSCovered

A9999	Miscellaneous DME supply or accessory, not otherwise specified; service area changed from C-Orthotics and Prosthetics to E-DME
E0251	Hospital bed; fixed height; with any type side rails, without mattress — coverage criteria specified
E0256	Hospital bed; variable height; hi-lo; with any type side rails, without mattress — coverage criteria specified
E0261	Hospital bed; semi-electric (head and foot adjustment) with any type side rails, without mattress — coverage criteria specified
E0266	Hospital bed; total electric (head, foot and height adjustments), with any type side rails, without mattress — coverage criteria specified
E0301	Hospital bed; heavy duty, extra wide; with weight capacity >350 lb ≤600 lb, with any type side rails, without mattress — coverage criteria specified

Hospital bedsHCPCSCovered

E0256	Hospital bed, variable height; hi-lo; with any type side rails, without mattress
E0261	Hospital bed, semi-electric (head and foot adjustment) with any type side rails, without mattress
E0266	Hospital bed; total electric (head, foot and height adjustments), with any type side rails, without mattress
E0301	Hospital bed, heavy duty, extra wide; weight capacity >350 to <=600 lbs
E0302	Extra heavy-duty hospital bed; weight exceeds 600 lbs
E0328	Hospital bed, pediatric; manual, 360-degree side enclosures, includes mattress

Pressure reducing support surfacesHCPCS

E0181	Powered pressure reducing mattress overlay/pad, alternating, with pump
E0193	Powered air flotation bed (low air loss therapy)
E0371	Non-powered advanced pressure reducing overlay for mattress
E0372	Powered air overlay for mattress

Oxygen systems and oximetersHCPCS

E0424	Stationary compressed gaseous oxygen system, rental
E0431	Portable gaseous oxygen system, rental
E0434	Portable liquid oxygen systems, rental
E0439	Stationary liquid oxygen system, rental
E1390	Oxygen concentrator, single delivery port
E1392	Portable oxygen concentrator; rental
E0445	Oximeter device for measuring blood oxygen levels non-invasively

Home ventilatorsHCPCS

E0465	Home ventilator, any type used with invasive interface
E0467	Home ventilator; multi-function respiratory device
E0468	Home ventilator, dual-function respiratory device

Respiratory and airway clearance codesHCPCSCovered

E0465	Home ventilator
E0466	Home ventilator
E0467	Ventilator (includes listed therapies/supplies)
E0468	Ventilator (includes listed therapies/supplies)
E0601	Continuous positive airway pressure (CPAP) device
E0470	Bi-level PAP (BiPAP)
E0471	BiPAP ST (with backup rate)
E0472	BiPAP ST (with backup rate, invasive)
E0480	Percussor; home model (airway clearance)
E0481	Intrapulmonary percussive ventilation system

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Walker attachments and pediatric gait trainer HCPCSHCPCSCovered

E0154F7	Platform attachment, walker, each (supports arm)
E015SF7	Wheel attachment rigid pick-up walker, per pair
E0156F4	Seat attachment, walker
EO0157F7	Crutch attachment, walker; each
E0159F7	Brake attachment for wheeled walker, replacement each
E800QF3	Gait trainer; pediatric size; posterior support; includes all accessories and components
E8001F3	Gait trainer, pediatric size, upright support; includes all accessories and components
E8002F3	Gait trainer, pediatric size, anterior support; includes all accessories and components

Examples of wheelchair and POV/PWC codes referencedHCPCSCovered

E1161	Manual adult size wheelchair, includes tilt-in-space
E1236	Wheelchair, pediatric size, folding, adjustable, with seating system (stroller-style mobility devices only); includes accessories
K0001	Standard wheelchair
K0003	Lightweight wheelchair
K0800	Power operated vehicle, base/repair code (used for prior approval of repairs)
K0801	Power operated vehicle, group standard up to 300 lbs
K0806	Power operated vehicle, group 2 standard up to 300 lbs

Group 2 / POV related codesHCPCS

K0806F3	Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds
K0808F3	Power operated vehicle; group 2 duty, patient weight capacity 301 to 450 pounds heavy
K0812F3	Power operated vehicle, not otherwise classified

Group 1 codesHCPCSCovered

K0813F3	Power wheelchair, group 1 standard, portable; sling/solid seat and back; patient weight capacity up to and including 300 pounds
K0814F3	Power wheelchair, group 1 standard, portable; captain's chair; patient weight capacity up to and including 300 pounds
K0816F3	Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds

Group 2 codes (standard/heavy/multiple options)HCPCSCovered

K0824F3	Power wheelchair, group 2 heavy duty, sling/solid seat/back; patient weight capacity 301 to 450 pounds
K0828F3	Power wheelchair, group 2 extra heavy duty, sling/solid seat/back; patient weight capacity 601 pounds or more
K0835F3	Power wheelchair, group 2 standard, single power option, sling/solid seat/back; patient weight capacity up to and including 300 pounds
K0841F3	Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back; patient weight capacity up to and including 300 pounds

Group 3 codesHCPCSCovered

K0848F3	Power wheelchair, group 3 standard, sling/solid seat/back; patient weight capacity up to and including 300 pounds
K0856F3	Power wheelchair, group 3 standard, single power option, sling/solid seat/back; patient weight capacity up to and including 300 pounds
K0861F3	Power wheelchair, group 3 multiple power option (examples listed for heavy duty variants)

Power wheelchair HCPCS groups and option codesHCPCSCovered

K0861-K0864	Group 3 power wheelchairs, multiple power option, weight capacities 301-600+ lbs
K0868-K0871	Group 4 power wheelchairs, no power options, various capacities
K0878-K0886	Group 4 single and multiple power option codes, various capacities
K0890-K0891	Group 5 pediatric single and multiple power option codes
K0898	Group 6 miscellaneous power wheelchair code

SPC and accessory codesHCPCSCovered

E0944-E1002	Seating/positioning components and wheeled mobility accessories (pelvic belts, trays, UESS, lateral supports, headrests, power seating systems, etc.)
E0986	Manual wheelchair accessory, push-rim activated power assist system

Representative wheelchair accessory HCPCS codesHCPCSCovered

E0992	Wheelchair accessory, elevating leg rest; complete assembly
E1002	Wheelchair accessory, power seating system, tilt only
E1003	Wheelchair accessory, power seating system, recline only, without shear reduction
E1004	Wheelchair accessory, power seating system, recline only, with mechanical shear reduction
E2298	Complex rehabilitative power wheelchair accessory, power seat elevation system
E2301	Wheelchair accessory, power standing system, any type
E2310	Electronic connection between wheelchair controller and one power seating motor (example E2310-series)

Wheelchair seat cushion codes (general, skin protection, positioning)HCPCSCovered

E2601	General use wheelchair seat cushion; width less than 22 inches
E2603	Skin protection wheelchair seat cushion; width less than 22 inches
E2605	Positioning wheelchair seat cushion; width less than 22 inches

Custom seating codesHCPCSCovered

E2609	Custom fabricated wheelchair seat cushion; any size
E2617	Custom fabricated wheelchair back cushion; any size

Wheelchair components and accessory codesHCPCSCovered

K0018	Detachable, adjustable height armrest; upper portion, replacement only
K0077	Front caster assembly, complete, with solid tire, replacement only
K0108	Wheelchair component or accessory, not otherwise specified

Miscellaneous DME codesHCPCSCovered

E0604	Hospital grade breast pump; electric (rental only)
E0619	Apnea monitor; with recording feature
B9004	Parenteral nutrition infusion pump; portable

Referenced HCPCS codesHCPCSCovered

E0630	Patient lift; hydraulic or mechanical; includes any seat; sling, strap(s) or pad(s)
E0627	Seat lift equipment (type not to be billed in combination with patient lift)
E0629	Seat lift equipment (type not to be billed in combination with patient lift)
E0637	Combination sit to stand frame/table system, any size including pediatric; with seat lift feature
E0638	Standing frame/table system, one position, any size
E0641	Standing frame/table system, multi-position, any size
E0642	Standing frame/table system, mobile (dynamic stander), self-propelled
E0650	Pneumatic compressor; non-segmental home model (lymphedema pump)
E0651	Pneumatic compressor; segmental home model without calibrated gradient pressure
E0652	Pneumatic compressor; segmental home model with calibrated gradient pressure (used for trunk/chest/abdomen involvement)

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Pneumatic compression and appliance codesHCPCSCovered

E0652	Pneumatic compressor; segmental model with manual chamber pressure control — covered for lymphedema when specific criteria met
E0650	Non-segmental pneumatic compressor (referenced as prerequisite coverage criteria)
E0651	Segmental pneumatic compressor without manual control (referenced as prerequisite coverage criteria)
E0656	Segmental pneumatic appliance for use with pneumatic compressor, trunk
E0657	Segmental pneumatic appliance for use with pneumatic compressor, chest
E0665	Non-segmental pneumatic appliance full arm

Electrical stimulation and osteogenesis stimulator codesHCPCSCovered

E0730	TENS device; covered for knee osteoarthritis with specified ICD codes
E0747	Osteogenesis stimulator, noninvasive; covered for nonunion long bone fractures with radiographic documentation
E0748	Osteogenesis stimulator for spinal applications; covered for failed spinal fusion situations
E0760	Low intensity ultrasound osteogenesis stimulator; covered for nonunion long bone fractures with radiographic documentation

Topical oxygen therapy codesHCPCS

A4575	Topical hyperbaric oxygen chamber, disposable (TOWT dressing/canister set) — billing code for topical oxygen wound therapy
E1390	Oxygen concentrator, single delivery port — billing code for TOWT concentrator

Negative pressure wound therapy codesHCPCS

E2402	Negative pressure wound therapy electrical pump; stationary or portable — billed as monthly rental (RR)
A6550	Wound care set for NPWT (supplies billed separately)
A7000	Canister; disposable used with suction pump

Speech generating device codesHCPCSCovered

E2500F2	Speech generating device; digitized speech; ≤8 minutes recording
E2502F2	Speech generating device; digitized speech; >8 to ≤40 minutes recording
E2504F2	Speech generating device; digitized speech; >40 minutes recording
E2508F2	Speech generating device; synthesized speech; physical contact access
E2510F2	Speech generating device; synthesized speech; multiple methods
E2511F2	Speech generating software program
E2512F3	Accessory for speech generating device, mounting system
E2599F3	Accessory for speech generating device, not otherwise classified

Infusion pump replacement batteriesHCPCSCovered

K0601F8	Replacement battery for external infusion pump; silver oxide; 1.5V
K0602F8	Replacement battery for external infusion pump; silver oxide; 3V
K0605F8	Replacement battery for external infusion pump; lithium 4.5V

Larynx and trachea prosthetics codes (examples)HCPCSCovered

L8510F3	Voice amplifier
L8511F7	Insert for indwelling tracheoesophageal prosthesis, replacement only

Repair and miscellaneous codesHCPCSCovered

K0739F9	Repair or non-routine service for DME requiring technician; labor component; per 15 minutes
A9900F7	Miscellaneous DME supply, accessory, and/or service component
A9999	Miscellaneous DME supply or accessory, not otherwise specified

Cranial remolding orthosis codeHCPCS

S1040F1

Cranial remolding orthosis, rigid, with soft interface, custom fabricated, includes fitting and adjustment

Representative HCPCS/L-codes in this sectionHCPCS | mixedCovered

S1040F1	Cranial remolding orthosis, rigid, with soft interface material, custom fabricated, includes fitting
L0452F4	TLSO, flexible; provides trunk support; upper thoracic region, prefabricated/custom entries referenced
L0480F6	TLSO, triplanar control; one piece rigid plastic shell, custom fabricated
L0621F4	Sacroiliac orthosis, flexible; pelvic-sacral support
L0625F4	Lumbar orthosis, flexible; provides lumbar support, prefabricated

Frequency / quantity updates (examples)

Examples of frequency updatesMultiple L-codes and other HCPCS had frequency/quantity changes (e.g., L2820 previous 1 unit → new 2 units; numerous L-codes changed from once/year (F6) to twice/year (F7)).

Provider responsibilities, authorization and documentation actions

Prior Authorization

Prior Authorization Required for Continuous Oximeters and Probes

A "continuous" oximeter (E0445) required for more than spot-checking (monitoring/recording/trending/alarms) requires prior approval. The prior approval request must include diagnosis/medical condition, current oxygen orders (if applicable), a treatment plan with parameters and interventions for abnormal readings (including oxygen titration orders), and documentation of caregiver availability/training. Continuous oximeters for short-term use (<6 months) are rented (monthly rental includes probes, cables, repair and maintenance); if needed beyond 6 months, submit for purchase prior approval (rental fees must be deducted from purchase price). Pulse oximeter probes (A4606) are included in the oximeter reimbursement; disposable probes limited to four per month and reusable probes limited to one per 12 months. Prior approval for oxygen probes is required when replacement is necessary for member‑owned equipment and must include fiscal order and invoice.

Continuous oximeter (E0445) requires prior approval when used for continuous monitoring/recording/alarms.
Short-term continuous oximeter (<6 months) = rental; monthly rental includes probes/cables/repair/maintenance.
Long-term continuous oximeter (>6 months) = purchase; purchase reimbursement includes probes/cables/supplies; subsequent supplies require approval.
Disposable pulse oximeter probes limited to 4/month; reusable probes limited to 1 every 12 months.
Prior approval for A4606 required for member‑owned equipment; submit fiscal order and invoice.

Definitions, references and contact information

DMEPOS Policy Manual (reference)

Reference manual locationDMEPOS Policy Manual is available on eMedNY.org and contains definitions, participation requirements, and basis of payment for Medicaid DMEPOS services.

PurposeServes as the authoritative source for code definitions, coverage criteria, fee schedule guidance, and provider responsibilities.

Provider useProviders should reference the DMEPOS Policy Manual and Fee Schedule on eMedNY for current coding, prior approval indicators, and billing requirements.

Provider contacts for billing, prior approval, and Medicaid help

Billing and prior approval contactsGDIT help desk: (800) 343-9000 for billing questions and electronic claim support; Bureau of Medical Review: (800) 342-3005 for prior approval and policy queries; NYRx Helpline: (800) 541-2831 for pharmacy-related assistance.

Policy Summary

PayerFidelis Care

PolicyDurable Medical Equipment, Prosthetics, and Orthotics procedure codes and coverage guidelines

Policy CodePolicy N/A

Change TypeCode, fee, frequency and authorization updates

Effective DateN/A

Next Review DateN/A

Key ActionProviders must follow new authorization types and submit prior approval documentation where required (e.g., continuous oximeters, pediatric gait trainers, NPWT extensions).

SourceLink

On This Page

Quantity / frequency limits and superscript frequency codes

Maximum units authorityThe max units listed on the DME Fee Schedule is the maximum allowed; fiscal orders exceeding this require prior approval.

Superscript frequency codesFrequency limitations are defined by superscript codes (F1–F26, e.g., F2 twice/lifetime, F3 once/3 years, F6 once/year, F7 twice/year, F26 continuous monthly rental).

Included accessories ruleAccessories/components included in a base code's MRA must be supplied at initial dispensing; no additional reimbursement within 90 days of dispensing.

Prior approval triggerPrior approval is required when the fiscal order exceeds the Fee Schedule amount, when frequency limits are exceeded, or when an underlined code/DVS indicator requires authorization.

Oxygen coverage thresholds and modifiers

Resting thresholdArterial PO2 ≤55 mm Hg or oxygen saturation ≤88% at rest (awake).

Sleep/exertion thresholdsPO2 ≤55 mm Hg or SpO2 ≤88% for ≥5 minutes during sleep; exercise criteria apply if daytime resting PO2 ≥56 mm Hg or SpO2 ≥89% and exercise demonstrates hypoxemia improved by oxygen.

PO2 56–59 mm Hg conditionsPO2 56–59 mm Hg (or SpO2 89%) may qualify if documented cor pulmonale, pulmonary hypertension, dependent edema, or erythrocythemia (hematocrit >56%).

Liquid oxygen limitsLiquid oxygen covered only for constant flow >5 LPM or members away from home long periods; members qualifying for liquid oxygen cannot receive other delivery systems concurrently.

CPAP adherence threshold (replacement criteria)

CPAP adherence definitionAdherence defined as ≥4 hours/night on ≥70% of nights during a consecutive 30-day period within the last 6 months.

Replacement documentationPrior approval for replacement before/after 5-year useful life requires in-person evaluation and objective compliance data (e.g., compliance graph printouts).

Time window for evidenceAdherence must be documented anytime within the last 6 months when submitting for replacement (face-to-face eval plus objective data).

Purchase price conversion for airway clearance devices (720 days)

Purchase price conversion periodPurchase price is reached at 720 days (24 months) of rental for specified airway clearance devices (e.g., intrapulmonary percussive ventilation, MI-E, HFCWO).

Devices referencedApplies to airway clearance devices including intrapulmonary percussive ventilation systems, cough stimulators, and high frequency chest wall oscillation systems as noted in device entries.

Billing implicationAfter purchase price reached, rental payments sum to the purchase price; fee schedule rental rules and prior approval requirements continue to apply for extensions or purchases.

POV repair prior approval and direct-bill thresholds

POV repair prior approval thresholdAll requested repairs and replacement parts for POVs should be submitted for prior approval using code K0800 with -RB unless the repair is less than 25% of the base code's MRA.

Direct billing allowanceRepairs less than 25% of the base code's MRA may be billed directly up to twice per year using the -RB modifier; more frequent or larger repairs require prior approval.

Labor coding and thresholdReport K0739 for labor component when applicable; K0739 labor fee is $18.00 per 15 minutes and more than 2 hours of labor requires prior approval.

Weight capacity thresholds (PWC/POV groups)

Weight capacity group bandsPower wheelchair/POV groups defined by weight capacity bands: ≤300 lb; 301–450 lb; 451–600 lb; >600 lb (heavy/extra heavy).

Group mapping examplesGroup codes (e.g., Group 1 standard ≤300 lb; Group 2 covers higher capacities up to 450 lb; Group 3–4 cover higher performance and heavier capacities).

Implication for codingSelect HCPCS group code consistent with member weight capacity and device group features; reimbursement and included accessories follow group rules.

Speed, range, and obstacle thresholds by PWC group

Group-specific performance thresholdsEach PWC group has minimum performance specs (e.g., Group 1: top speed 3 mph, range 5 miles, obstacle climb 20 mm; Group 3: top speed 4.5 mph, range 12 miles, obstacle climb 60 mm).

Additional featuresHigher groups require features like drive wheel suspension, greater dynamic stability, expandable controllers, or capacity for multiple power options.

Assessment requirementMember's mobility needs must match group performance (speed, range, obstacle capability) and be documented to justify group selection.

E2298 cost+51% cap and invoice requirement

Cost+51% allowance for E2298E2298 (power seat elevation) may be billed as invoice cost + 51% provided an invoice is submitted; cost+51% pricing will not exceed the DMEPOS Fee Schedule amount for E2298.

Invoice requirementAn invoice is required when billing E2298 as cost+51% to substantiate cost basis; reimbursement is capped at the Fee Schedule fee.

Eligible basesE2298 can only be used on K0835–K0898 complex power wheelchair bases (rare exceptions for non-complex bases require KO108).

Wheelchair confinement threshold for skin protection cushions

Wheelchair confinement threshold for skin protection cushionsMember confined to wheelchair more than four (4) continuous hours daily qualifies as one criterion for skin protection seat cushion eligibility (E2603/E2604).

Additional qualifying conditionsSkin protection cushions also require meeting SPC guidelines and having diagnoses such as spinal cord injury, MS, cerebral palsy, ALS, traumatic brain injury, etc.

DocumentationEvaluator must document hours of confinement and relevant diagnoses or inability to perform functional weight shifts to support cushion coverage.

Lymphedema and CVI conservative therapy trial requirements

Lymphedema conservative trial durationA documented 4-week trial of conservative therapy is required showing failed response before PCD coverage for lymphedema (measurements, compression compliance, exercise, elevation).

CVI ulcer additional requirementFor chronic venous insufficiency (CVI) with venous stasis ulcers, a six-month conservative therapy trial is required, which must include the 4-week lymphedema trial elements plus appropriate wound care and debridement where indicated.

Documentation specificsTrial must include detailed measurements over time, evidence of compliance with compression (minimum 30 mmHg distally), and participation in MLD when applicable.

Insulin pump prior therapy duration

Insulin pump prior therapy durationExternal ambulatory insulin pump (E0784) candidates must have been on a program of multiple daily injections (≥3 injections/day) with frequent self-adjustments for at least 6 months prior to pump initiation and have failed to achieve acceptable control not explained by poor motivation or compliance.

Additional criteriaPatient must meet one or more control failure criteria (e.g., HbA1c >7%, recurrent hypoglycemia, wide glucose fluctuations) and complete comprehensive diabetes education.

Ordering/coverage noteInsulin pump coverage requires ordering by an endocrinologist or practitioner experienced in continuous subcutaneous insulin infusion therapy; disposable pump supplies may be covered under the Preferred Diabetic Supply Program.

Minimum conservative therapy before cranial remolding orthosis

Minimum conservative therapy duration before cranial remoldingA documented minimum 2-month trial of repositioning and stretching exercises is required prior to consideration of a cranial remolding orthosis (S1040).

Required conservative measuresTrial should include alternating back/side sleeping, supervised tummy time, rearranging crib relative to light source, limiting supine time, limiting stroller/carrier/swing time, neck motion exercises and rotated positioning activities.

Ordering and documentationValid fiscal order signed by pediatrician/general surgeon (pediatric specialty) or craniofacial surgeon plus anthropometric measurements and documentation of medical necessity from pediatric neurosurgeon/craniofacial surgeon required for prior approval.

Documentation Required

Billing and Documentation Responsibility

Providers are responsible for maintaining complete medical records demonstrating that members meet coverage criteria for all DME, prosthetics, orthotics, and wheeled mobility items. Documentation must support medical necessity, list included supplies, and be available for audit or upon request. For rentals, the 30‑day rental fee includes necessary supplies and accessories; suppliers must not bill separately for items included in base codes. When cost+51% pricing is used (E2298), an invoice is required and cost+51% will not exceed the DMEPOS fee schedule amount.

Suppliers must retain practitioner's documentation of medical necessity and the written order; obtain signed fiscal order within 30 days if telephoned/faxed.
Rental payments include delivery, maintenance, repairs, and necessary supplies; spot‑check oximeters are included in oxygen system rentals and should not be billed separately.
Providers must maintain documentation that member meets ventilator and other device coverage criteria and note which supplies are included in base codes.
Invoice required when billing E2298 as cost+51%; cost+51% capped at DMEPOS fee schedule.

Prior Authorization

Prior Authorization and Documentation Submission Requirements

Prior authorization or DVS authorization rules vary by item: submit fiscal order, supporting clinical documentation, and itemized quotes/invoices as required. For devices requiring prior approval, include the signed fiscal order, manufacturer's quote or make/model/price, and any required attestation(s). Positioning bath chairs/stand additions (E1399) must be submitted on a single separate prior approval line with order and manufacturer's quote. For oxygen wound therapy (A4575), initial DVS authorization is limited (see TOWT callout) and prior approval is required for treatment exceeding initial days.

Include signed fiscal order and either manufacturer quote or invoice with prior approval requests.
Positioning bath chairs/stand additions: submit singularly on one prior approval with order and manufacturer's quote/model.
TOWT (A4575) initial electronic DVS auth limited to 16 days in a 28‑day period; prior approval required for treatment >4 weeks and for extensions submit wound healing documentation.
DVS authorization available for hospital‑grade breast pumps up to 2 months; prior approval required if >2 months rental.

Documentation Required

Documentation and Attestation

When documentation from therapists or other licensed/certified medical professionals is submitted (e.g., wheelchair/SEATING evaluations), the supplier must include a signed attestation that the evaluator has no financial relationship with the supplier. Documentation must include therapist credentials, evaluation date, contact information, and sufficient clinical detail (history, exam, functional assessment) to support medical necessity.

Supplier attestation required when using therapist-completed evaluation forms: must state no financial relationship between evaluator and supplier.
Therapist documentation must include name, licensure, evaluation date, phone number, address, and employer.
Comprehensive history and physical, and evaluation details (strength, ROM, tone, balance, ADLs) must be maintained.

Prior Authorization

Coverage Prerequisites and Prior Authorization for Power Wheelchairs (PWC)

Power Wheelchairs (PWC) are covered only if general PMD criteria are met and the member additionally meets PWC‑specific criteria. Prior approval requests must document the member’s ability to safely and independently operate the power wheelchair, weight capacity considerations, and home/community environmental access. Suppliers must include a detailed wheelchair evaluation and demonstrate that POV criteria do not apply when relevant.

Member must meet basic PMD coverage criteria and PWC criteria 10–13 (including mental/physical ability to operate the device independently).
Document that the member's weight is within wheelchair capacity and that home/community environments permit safe operation.
If multiple power options are requested, document medical necessity for each power option and relevant trials/justifications.

Prior Authorization

Authorization and Documentation Requirements for SPC and Power Assist

Seating and Positioning Components (SPC) and power assist devices (including E0986 and power seating codes E1002–E1008) require thorough documentation: confirm WME criteria are met, include an upper extremity assessment for power assist, document a successful trial in customary environments, and provide a clear medical necessity justification distinguishing SPC/power assist from a power wheelchair. The member must have the mental and physical ability to safely and independently operate powered seating features.

Upper extremity assessment (ROM, strength, tone, gross/fine motor skills) required for E0986 power assist.
Documentation of a detailed, successful trial in varied customary environments for power assist devices.
For power seating systems (E1002–E1008), document that member meets SPC criteria 1–3 and can safely operate power tilt/recline functions.
Selection of power seating must be medically justified; caregiver convenience alone is not sufficient.

Prior Authorization

Prior Authorization and Documentation for Power Standing Components

Power standing components require prior authorization with comprehensive supporting documentation. Submit a fiscal order and a Letter of Medical Necessity (LOMN) containing a complete history and physical, wheelchair evaluation by qualified rehab professionals, detailed functional assessment (strength, ROM, tone, balance, ADLs), documentation of trials of less costly alternatives, home therapy plan, caregiver assistance level, and an itemized list of all current DME. Demonstrate evidence‑based justification for power standing over static standers and document ability to manage chest and knee supports and tolerance for standing.

Fiscal order from qualified provider required for power standing component prior authorization.
LOMN must include comprehensive history/physical, summary of condition, prognosis, and co‑morbidities.
Wheelchair evaluation by physiatrist or rehab therapist experienced in complex rehab required; include trials of less costly alternatives and home therapy plan.
Document caregiver assistance, itemized current DME, and clinical justification why static standers/tilt tables are insufficient.

Billing Rule

Invoice Requirement and Documentation for E2298 (Power Seat Elevation)

For E2298 (power seat elevation) billed using cost+51% pricing, an invoice is required with the prior approval/purchase request. Cost+51% pricing will not exceed the DMEPOS Fee Schedule amount for E2298. Prior approval must show the member meets PMD criteria, can safely operate the power seat function, and that selection is based on medical need rather than caregiver convenience.

Invoice required when billing E2298 as cost+51%.
Cost+51% reimbursement capped at DMEPOS Fee Schedule for E2298.
Document member's mental and physical ability to safely operate power seat elevation and justification for selection.

Documentation Required

Documenting Member Ability to Operate Power Seating

Members must be documented to have the mental and physical ability to safely and independently operate power seating functions (tilt, recline, power seat elevation) before prior authorization is granted. Documentation must describe the member's cognitive status, motor control, ROM, strength, tone, and demonstrated safe operation during trials or evaluation.

Document cognitive ability to understand and safely operate powered seating functions.
Include findings from functional assessments (ROM, strength, tone) and evidence from trials/observations demonstrating safe independent operation.
If member cannot safely operate functions independently, prior authorization is unlikely unless clear mitigations are documented.

Prior Authorization

Prior Authorization Requirements for Hospital‑Grade Breast Pumps and Apnea Monitors

DVS authorization is required for hospital/professional grade breast pumps for up to 2 months; prior approval is required for rentals exceeding 2 months (e.g., extreme prematurity). Apnea monitors for infants under 1 year require electronic DVS prior authorization and must be ordered by board‑certified pulmonologists or neonatologists; apnea monitors are rented and the monthly fee includes all necessary features and accessories. Prior approval is required for apnea monitors for members over 1 year of age.

DVS authorization available for hospital‑grade breast pumps up to 2 months; prior approval required for >2 months.
Apnea monitors (age <1 year): electronic DVS prior auth required; orders must be from board‑certified pulmonologists or neonatologists.
Apnea monitors are rental items; monthly rental includes delivery, maintenance, repairs, parts, supplies, and back‑up equipment as needed.
Prior approval required for apnea monitors for members >1 year.

Billing Rule

Rental Payment Caps for Infusion Pumps

Infusion pumps (ambulatory and parenteral) have specified rental caps. The maximum monthly rental amount for infusion pumps (B9004, B9006, E0781, E0791) is $60.60. The maximum daily rental for a parenteral infusion pump for short‑term use is $5.00 per day up to a total of $60.60 per month. Ensure prior approval documentation demonstrates the pump and therapy are appropriate for home use and that physician supervision is specified.

Maximum monthly rental for infusion pumps (B9004, B9006, E0781, E0791) = $60.60.
Maximum daily short‑term parenteral pump rental = $5.00/day up to $60.60/month.
Prior approval/coverage requires documentation that pump and therapy are appropriate for home use and physician oversight is specified.

Prior Authorization

Prior Approval Process for Positioning Bath Chairs and Stand Additions

Positioning bath chairs and stand additions require prior approval submitted as E1399. The DME provider must obtain a valid order and supporting medical documentation, and include a manufacturer's quote or the item's make/model and price. These items must be submitted singularly on a separate prior approval line; the DME Provider will be issued a prior approval priced up to the established MRA and may bill Medicaid upon dispensing.

Code positioning bath chairs/stand additions as E1399 and submit prior approval with valid order and manufacturer's quote/make and model.
Submit these items singularly on a separate prior approval from other items.
DME Provider will receive prior approval priced up to established MRA and may bill upon dispensing.

Prior Authorization

Prior Authorization for Topical Oxygen Wound Therapy (TOWT)

Topical Oxygen Wound Therapy (TOWT) supplies (A4575) and related equipment have DVS and prior approval rules: payment for A4575 includes the dressing set and canister and is payment in full for TOWT; an initial electronic DVS prior authorization will be granted for A4575 for up to 16 days in a 28‑day period (treatment pattern 4 days on, 3 days off). Prior approval is required for treatment exceeding 4 weeks and for extensions; submit documentation of prior treatments, wound measurements, exudate, presence of granulation/necrosis, and patient compliance. E1390 is prior authorized (DVS) and billed monthly.

Initial electronic DVS auth for A4575 limited to 16 days in a 28‑day period; prior approval required for treatment >4 weeks.
When requesting extensions, submit weekly quantitative wound measurements and documentation of compliance and prior treatment regimens.
E1390 (oxygen concentrator for TOWT) requires prior authorization (DVS) and is billed monthly.

Prior Authorization

Prior Authorization and Continued Coverage for Tumor Treating Fields Therapy (E0766)

Tumor Treating Fields Therapy (E0766) initial prior approval will be granted for 3 months when criteria are met. Continued coverage beyond the first three months requires a clinical re‑evaluation between day 60 and 91 after therapy initiation demonstrating ongoing use and benefit. Documentation must include re‑evaluation by the treating practitioner and objective evidence of adherence (average 18 hours/day).

Initial prior approval for E0766 granted for 3 months if criteria are met.
For continued coverage, treating practitioner must re‑evaluate patient between day 60 and 91 and document clinical benefit.
Objective adherence evidence required: average use of 18 hours per day (excluding medically documented interruptions).

Prior Authorization

Prior Authorization for Negative Pressure Wound Therapy (NPWT)

Negative Pressure Wound Therapy (NPWT, E2402) is billed as a monthly recurring rental; initial 30 days are allowed without prior approval. Supplies (A6550, A7000) are billed separately. Extensions beyond the initial period require prior approval with documentation of wound status and continued medical necessity.

E2402 initial 30 days allowed without prior approval (monthly recurring rental thereafter).
Supplies (A6550, A7000) billed separately; pump provides included functionality and alarms.
Prior approval required for extensions beyond initial 30 days; submit wound healing documentation.

Prior Authorization

Prior Approval and Documentation Requirements for Speech Generating Device (SGD) Repair/Replacement

Speech Generating Device (SGD) repair or replacement prior approvals must document why the current device is no longer effective, include a manufacturer quote comparing repair versus replacement costs, and demonstrate minimum coverage criteria are met. For repairs, include part-specific cost quotes or invoices and anticipated useful life post‑repair; if device was not Medicaid‑funded originally, provide serial number, date provided, funding source, and original supporting documentation.

Document why existing SGD no longer meets functional communication needs and what changes necessitate replacement.
Include manufacturer quote for repair cost vs replacement; decision based on cost‑effectiveness.
Repair requests must include specific parts, cost quotes/invoices, list of other non‑prior approval repairs, and anticipated useful life after repair.
If device was not Medicaid‑funded originally, provide serial number, original documentation, and funding source.

Prior Authorization

Prior Approval for Positioning Car Seats and Repair Documentation

Positioning car seats and associated custom accessories may require prior approval. Coverage criteria include medically necessary postural needs that cannot be met by vehicle restraint systems, caregiver vehicle use, and size/postural restrictions preventing standard seats. Reimbursement includes head support, trunk positioning pads, harnesses, abductor pommel, wedges, tilt/recline, LATCH/tether straps. Repair requests must include specific part(s) and associated cost quotes or invoices.

Car seats covered when postural needs cannot be met by less costly alternatives and primary use is in caregiver's personal vehicle.
Reimbursement includes listed positioning features; additional accessories require prior approval under E1399.
Repair submissions must include part-specific quotes/invoices and list of other repairs not requiring prior approval.

Prior Authorization

Prior Authorization and Documentation for Cranial Remolding Orthoses

Cranial remolding orthoses (helmets) prior authorization requires a fiscal order signed by an appropriate specialist (pediatrician/craniofacial surgeon), anthropometric measurements, documentation of medical necessity from a pediatric neurosurgeon or craniofacial surgeon, and a documented trial of repositioning/stretching for at least 2 months. Include anthropometrics and trial documentation with the prior approval submission.

Valid fiscal order signed by pediatrician or craniofacial specialist required.
Provide anthropometric measurements and documentation from pediatric neurosurgeon or craniofacial surgeon.
Include documentation of at least a 2‑month trial of repositioning and stretching exercises.

Prior Authorization

Clinical Indications and Prior Authorization for Spinal Orthoses

Spinal orthoses are covered when ordered for specific clinical indications such as pain reduction by restricting trunk mobility, to facilitate postoperative or injury healing of the spine or related soft tissues, or to support weak spinal muscles or spinal deformity. Prior approval documentation should include indication, clinical rationale, and any supportive imaging or operative reports as applicable.

Common indications: reduce pain by restricting trunk mobility; facilitate healing after injury/surgery; support weak spinal muscles or spinal deformity.
Provide clinical indication, rationale, and relevant supporting documentation (imaging, operative reports) with the prior approval request.

Modifiers guidance (KO–K4, -LT/-RT, -RB, -RR, -U3)

Common modifiers and useFunctional ambulation modifiers (~KO through -K4), side-specific modifiers (-LT/-RT), and repair/replacement (-RB) should be appended when appropriate per code descriptions.

-RB specifics-RB (Replacement/Repair) allowed twice per year for patient-owned devices; more frequent repairs require prior approval; -RB not needed when a specific replacement part code exists.

Other modifiers-RR indicates rental; -U3 used for repair/replacement when member is in hospital or SNF; ensure correct modifier use for accurate billing.

Fee schedule and prior approval indicators

Prior approval / DVS indicatorsAn underlined procedure code requires prior approval; a '#T' indicates DVS authorization is required; items neither underlined nor #T are direct bill items per the Fee Schedule.

Fee schedule authoritativeFees and purchase/rental rules are published in the DME Fee Schedule section of the DME Manual on eMedNY and govern reimbursement.

Action when in doubtRefer to the Fee Schedule and the DMEPOS Policy Manual for code-specific authorization indicators and obtain prior approval when indicated.

Included accessories and component reimbursement rule

Included accessories ruleAccessories/components included in a base code's Maximum Reimbursement Amount (MRA) must be supplied at initial dispensing; no additional reimbursement will be made for these items within 90 days of dispensing.

Supplier obligationIf an included accessory is required within 90 days, the provider should supply it at no additional charge to the member.

Implication for billingDo not bill separately for included accessories within the 90-day window; use replacement codes and -RB modifier for later replacement when applicable.

Hospital bed definitions and coverage notes

Hospital bed types and coverageHospital beds (fixed, variable/hi-lo, semi-electric, total electric, heavy/extra heavy, pediatric enclosed) are covered when member meets specified clinical and functional criteria (e.g., head elevated >30°, traction needs, transfer height requirements, weight capacity).

Documentation requirementsEvaluation by qualified practitioner and documentation of medical necessity, functional status, and alternatives considered are required for certain beds (especially pediatric enclosed beds).

Accessory and rental rulesUse -RR for rentals; rental rules, included accessories, and prior approval indicators follow Fee Schedule and policy guidance.

Pressure reducing support surface definitions

Pressure reducing surface groupsGroup 1 and Group 2 pressure reducing support surfaces defined with specific clinical criteria: Group 1 for immobile/limited mobility with pressure ulcer risk factors; Group 2 for larger/more severe ulcers or failed Group 1 therapy ≥1 month.

Clinical indicationsCovered when member is bedridden or wheelchair-bound and conventional cushioning has failed; specific staging and treatment history required for Group 2.

ExclusionsAir-fluidized beds are not covered for home use.

Home oxygen therapy (definition and thresholds)

Home oxygen therapy definitionHome oxygen therapy is oxygen delivered and managed at home as an integral part of a documented medical treatment plan, ordered in writing and supported by blood gas/SpO2 criteria.

Delivery systems noteIncludes concentrators, compressed gaseous systems, liquid oxygen and portable systems; liquid oxygen limited to high-flow or frequent away-from-home use.

Documentation and re-orderingDMEPOS provider must maintain practitioner's documentation; oxygen must be re-ordered at least every 365 days.

PAP device definitions and coverage

CPAP and BiPAP device definitionsPAP devices include CPAP (E0601) for obstructive sleep apnea and BiPAP (E0470) or BiPAP ST (E0471/E0472) for specified respiratory disorders; BiPAP ST includes a backup rate feature.

Coverage contextCPAP requires diagnostic sleep study criteria; BiPAP covered for members who failed CPAP or have restrictive thoracic disorders, severe COPD, CSA/CompSA, or hypoventilation.

Replacement/use notesCPAP replacement before/after 5-year useful life requires in-person evaluation and objective compliance evidence (adherence defined per policy).

Airway clearance devices (definition)

Airway clearance device definitionAirway clearance devices (E0480–E0483) manage pulmonary secretions (percussors, intrapulmonary percussive ventilation, cough stimulators, HFCWO); requests must document underlying diagnosis, need, treatment plan, settings, and training.

Purchase price conversionSome airway clearance devices reach purchase price at 720 days (24 months) of rental (purchase conversion applies as noted in device entries).

Documentation requiredInclude frequency of use, settings on fiscal order, and training provided to member/caregiver with prior approval submissions as needed.

WME and SPC definitions

WME/SPC definitionWheeled mobility equipment (WME) includes manual wheelchairs, PMDs, PWCs, POVs and PADs; SPCs are seat, back and positioning components to optimize function.

Evaluation requirementWME/SPC requires evaluation by qualified practitioner experienced in wheelchair evaluation and ordering; practitioner must have no financial relationship with supplier.

Least-cost alternative principleIf requested WME/SPC criteria not met, payment based on least costly medically appropriate alternative considering weight, seating needs, and intended use.

MRADL (mobility-related ADL) context

MRADL definition contextMobility-Related Activities of Daily Living (MRADLs) are activities whose performance is significantly impaired by the member's mobility limitation and that justify WME coverage when impaired.

Assessment implicationWME coverage depends on demonstrating significant impairment in MRADLs that cannot be resolved with less intensive aids (cane/walker).

DocumentationEvaluator must document specific MRADLs affected and how the device will improve participation in these activities.

Custom-made wheelchair (definition)

Custom-made wheelchair definitionCustom-made wheelchair: frame uniquely constructed or substantially modified for a specific member; covered only when feature needed is not available in manufactured wheelchairs or accessories.

Assembly vs customAssembling modular components or using customized options does not by itself qualify as custom-made; must be unique construction.

DocumentationProvide documentation establishing why prefabricated alternatives fail to meet specific member needs when requesting custom-made seating.

Sling/solid seat and Captain's chair definitions

Sling/solid seat vs Captain's chairSling/solid seat is a rigid metal/plastic seat with minimal padding; Captain's chair is an automotive-style cushioned one- or two-piece seat used as a complete seating/cushioning system.

Coding implicationCaptain's chair codes apply for stadium-style or automotive-style seats; when medically necessary, position/skin protection codes should be used instead.

Use in PWCsSelect appropriate seat/back coding per actual seating system provided (sling/solid seat, captain's chair, or SPC cushions/back).

Proportional control and power options definitions

Proportional control input device definitionA proportional control input device translates a user's drive command into non-discrete directional and speed movement (continuous control).

Power options definitionPower options include tilt, recline, elevating seat, and power standing features that can be added to PWCs for seating and positioning assistance.

Coverage implicationPower options require meeting SPC and PWC criteria plus documentation of ability to safely operate and medical need for the power function.

Upper Extremity Support System (UESS) definition

UESS definition and limitUpper Extremity Support System (UESS) is an upper-extremity tray for positioning (not for ADLs); dimensions limited to forearm positioning length (~12–15 inches); not covered when used solely for ADLs.

Included itemsUESS MRA includes mounting hardware and cut-outs; additional positioning accessories may be separately billable if criteria met.

Coverage caveatBill UESS only when medical positioning need cannot be met by less costly alternatives (belts, harnesses, armrest modifications).

Power seat elevation (E2298) definition and constraints

E2298 definition and limitsE2298 (power seat elevation) is a complex rehabilitative power wheelchair accessory limited to complex power bases (K0835–K0898) and requires member to meet PMD criteria and demonstrate ability to safely operate the power seat; selection must be medically necessary.

Cost+51% billingInvoice required for cost+51% billing for E2298; cost+51% payment will not exceed the Fee Schedule amount for E2298.

Caregiver convenience exclusionSelection must not be based solely on caregiver convenience; less costly adaptations must be considered and documented.

Power standing system (E2301) definition and documentation

E2301 power standing system definitionE2301 is a power standing system component enabling upright/standing positioning on a power wheelchair; requires specific medical justification, trials, and documentation including LOMN and detailed wheelchair evaluation.

Documentation requirementsSubmit fiscal order, Letter of Medical Necessity, comprehensive H&P, wheelchair evaluation by qualified clinician, trial data of less costly alternatives, and home therapy/standing program.

Clinical prerequisitesMember must tolerate standing (no orthostatic hypotension/POTS/brittle bone disease), have independent management of chest/knee supports, and have been trialed on static standers.