MVP Health Care Non-Covered Items (Durable Medical Equipment / HCPCS list)
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List of specific HCPCS/DME codes and whether they are covered across MVP Health Care lines of business (Commercial, ASO, Medicare, Medicaid); used to determine denials and prior-authorization requirements for durable medical equipment and related items.
No material clinical or coverage changes in this revision.
Per-code Coverage Determinations
Per-code coverage entries
Coverage determinations are provided for each HCPCS code by line of business; codes marked "not covered" will be denied.
Examples
- A4210 — NEEDLE-FREE INJECTION DEVICE, EACH. Commercial = not covered; ASO = not covered; Medicare = not covered; Medicaid = not covered.
- A4250 — URINE TEST OR REAGENT STRIPS OR TABLETS (100 TABLETS OR STRIPS). Commercial = covered; ASO = covered; Medicare = not covered; Medicaid = covered.
- A9276 — SENSOR, INVASIVE, DISPOSABLE, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLY. Commercial = not covered; ASO = not covered; Medicare = not covered; Medicaid = not covered.
HCPCS / DME Code Listings and Scope
Prior Authorization and Denial Notices
Prior authorization and denial rule
Refer to the MVP Durable Medical Equipment Prior Authorization List to determine if a code requires prior authorization; codes that are not covered will be denied.
Check the MVP DME Prior Authorization List
Providers must consult the separate MVP Durable Medical Equipment Prior Authorization List to verify whether prior authorization is required for the specific HCPCS/DME code before submitting claims.
- Codes that are not covered will be denied.
Medical Necessity Determinations
Medical necessity
Medical necessity is determined per HCPCS code and line of business. This list specifies coverage status but does not provide clinical medical-necessity criteria; prior authorization policies hold the detailed criteria.
Operational note
- Codes explicitly listed as 'not covered' will be denied when billed for the indicated line of business.
- Coverage exceptions, benefit checks, or ASO-specific variations should be verified through plan-specific benefit files or prior authorization processes.
Key Definitions and Denial Conditions
Rental and Purchase Provisions
| Rule | Details / policy text |
|---|---|
| Rental vs. Purchase determination | |
| This document lists per‑code coverage determinations and does not specify separate rental vs. purchase billing rules. Providers must follow standard benefit plan language and the MVP Durable Medical Equipment Prior Authorization List to determine if an item should be rented or purchased and whether prior authorization is required. Codes listed as 'not covered' will be denied. |
Replacement Policies
Items Explicitly Not Covered
This policy identifies numerous HCPCS/DME items that are not covered by MVP Health Care and will be denied when billed. Codes listed as non-covered span a wide range of durable medical equipment and supplies — for example, A4210 (NEEDLE-FREE INJECTION DEVICE), A4490 (SURGICAL STOCKINGS ABOVE KNEE LENGTH), and A4520 (INCONTINENCE GARMENT, ANY TYPE) are all marked not covered across Commercial, ASO, Medicare and Medicaid in the line-item list provided in the document.
Additional examples of items designated not covered include disposables and accessories such as A4554 (DISPOSABLE UNDERPADS) and a variety of continuous glucose monitoring components — e.g., A9276 (SENSOR, INVASIVE, DISPOSABLE), A9277 (TRANSMITTER, EXTERNAL), and A9278 (RECEIVER) — all listed as not covered for relevant lines of business. The list also contains many mobility, bathing and home equipment items (for example, E0240 Bath/Shower Chair, E0248 Transfer Bench/Hospital Bed entries) and orthoses/prosthetic supplies that are documented as not covered in the source document.
Refer to the full line-item listing in this document to confirm coverage status by line of business for any specific HCPCS code; codes marked not covered will be denied. For prior authorization requirements or clinical criteria, providers should consult the separate MVP Durable Medical Equipment Prior Authorization List referenced in the policy.
Documentation and Reference Lists
Consult the separate prior authorization list
Prior authorization requirements are maintained on a separate MVP Durable Medical Equipment Prior Authorization List; providers should check that list for any code-specific authorization requirements prior to billing.
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