CurrentHighmark PennsylvaniaPolicy N/A

Physician office DME supply list for Medicare Advantage

A list of durable medical equipment (DME) supplies that may be provided in the physician office setting to Highmark Medicare Advantage members and billed fee-for-service; applies to Highmark Pennsylvania Medicare Advantage products with DME benefits.

Policy Summary

PayerHighmark Pennsylvania

PolicyPhysician office DME supply list for Medicare Advantage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionThese supply items do not require authorization; direct members to a participating network vendor for items not on this list.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No authOffice-supplied DME authorization requirement

Medicare AdvantageApplies to product type

May applyCost-sharing note

ChiropractorsStatutory exclusion

Multiple L-codesNumber/type of listed items

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Physician Office DME Coverage Criteria

Physician office DME coverage criteria

Covered when the following conditions are met:

Items listed by HCPCS may be supplied in the physician office and billed to Highmark for Medicare Advantage members without prior authorization; member cost-sharing may apply.

This list applies only to Highmark Medicare Advantage products with DME benefits.

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

The Medicare definition of physician includes: Doctor of Medicine; Doctor of Osteopathy; Doctor of Dental Surgery or Dental Medicine; Doctor of Podiatry or Surgical Chiropody; Doctor of Optometry; Physician Assistant; Nurse Practitioner; Clinical Nurse Specialist.

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

HCPCS / Billing Codes

Physician office DME HCPCS listHCPCSCovered

A4561	Pessary, rubber, any type
A4562	Pessary, non rubber, any type
A4566	Shoulder sling or vest design, abduction restrainer, prefabricated, includes fitting and adjustment
A4614	Peak expiratory flow rate meter, hand held
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
E0114	Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips
L0120	Cervical, flexible, non-adjustable (foam collar)
L0140	Cervical, semi-rigid, adjustable (plastic collar)
L0450	Thoracic-lumbar-sacral orthosis, flexible, prefabricated, includes fitting and adjustment

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Provider Actions and Billing Notes

Prior Authorization

No prior authorization required for listed office-supplied DME

These supply items listed on the physician office DME supply list do not require prior authorization for Highmark Medicare Advantage members; however, member cost-sharing may apply.

Billing Rule

Route non-listed items to participating network vendors

For items not included on this physician office DME supply list, direct Pennsylvania Medicare Advantage HMO and Freedom Blue PPO members to obtain the items from a participating network vendor.

Definitions and Scope

Physician (Medicare definition) and chiropractic exclusion

Medicare definition of physicianDoctor 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 (DPM); Doctor of Optometry (OD); Physician Assistant (PA); Nurse Practitioner (NP); Clinical Nurse Specialist.

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

Exception to chiropractic exclusionDME items/supplies ordered or supplied by a Doctor of Chiropractic will be denied unless there is a valid ancillary service provider contract with Highmark.