CurrentHighmark Blueshield NenyPolicy N/A

Physician office DME supply list for Medicare Advantage

Lists durable medical equipment (DME) supply items that physicians and other authorized practitioners may supply in-office to Highmark Medicare Advantage members and bill fee-for-service; applies only to Highmark Medicare Advantage products with DME benefits and informs billing and vendor direction.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPhysician office DME supply list for Medicare Advantage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionThese supply items do not require authorization; for items not on the list, direct Pennsylvania Medicare Advantage HMO and Freedom Blue PPO members to a participating network vendor.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

no prior authItems do not require authorization

dozensHCPCS supply items listed

Medicare Advantage onlyProduct scope

vendor referralOff-list routing (PA members)

In-office DME Supply Coverage

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.

Representative HCPCS Codes

Representative HCPCS codes listedHCPCSCovered

A4561	Pessary, rubber, any type
A4627	Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
E0112	Crutches underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips
L0140	Cervical, semi-rigid, adjustable (plastic collar)
L0450	Thoracic-lumbar-sacral orthosis, flexible, prefabricated, includes fitting and adjustment
L0621	Sacroiliac orthosis, flexible, prefabricated, includes fitting and adjustment
L1830	Knee orthosis, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment
L1902	Ankle-foot orthosis, ankle gauntlet, prefabricated, includes fitting and adjustment
L3260	Surgical boot/shoe, each
L3677	Shoulder orthosis, hard plastic, shoulder stabilizer, prefabricated, includes fitting and adjustment

1–10 of 13

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Authorization and Vendor Routing

Prior Authorization

No prior authorization required for listed in-office DME supplies

These supply items do not require authorization. Member cost-sharing may apply; items listed may be supplied in-office and billed fee-for-service to Highmark Medicare Advantage. This applies only to Highmark Medicare Advantage products with DME benefits.

Supply items on this list: no prior authorization required
Member cost-sharing may apply
Billed fee-for-service to Highmark Medicare Advantage

Billing Rule

Route off-list items to participating network vendor

For items not on this list, direct Pennsylvania Medicare Advantage HMO and Freedom Blue PPO members to a participating network vendor.

Applies only to Pennsylvania Medicare Advantage HMO and Freedom Blue PPO members for off-list items
Use a participating network vendor for procurement and billing

Provider and Exclusion Definitions

inv-07: Medicare definition of physician

Definition (Medicare)Physician = Doctor of Medicine (MD); Doctor of Osteopathy (DO) including osteopathic practitioner; Doctor of Dental Surgery or Dental Medicine (DDS/DMD); Doctor of Podiatry or Surgical Chiropody; Doctor of Optometry; Physician Assistant; Nurse Practitioner; Clinical Nurse Specialist.

ScopeApplies where entities are legally authorized to practice by the state in which services are rendered and subject to state scope-of-practice limitations.

ContextThis Medicare definition is provided for identifying which practitioners may supply in-office DME items to Highmark Medicare Advantage members.

inv-08: Chiropractic exclusion

Statutory exclusionMedicare coverage for all DME items and supplies ordered or supplied by a Doctor of Chiropractic is statutorily excluded.

Claim handlingAll DME items and supplies ordered for or supplied by a Doctor of Chiropractic for Highmark Medicare Advantage members will be denied unless there is a valid ancillary service provider contract with Highmark.

Operational noteIf a valid ancillary service provider contract exists with Highmark, DME items/supplies from a Doctor of Chiropractic may be considered; otherwise deny.