Neighborhood Health Plan DME HCPCS Coverage Prior Auth

Per-HCPCS Coverage Determinations and Limits

Per-item coverage entries (excerpt)

Per-item coverage entries (excerpt) — line-item coverage rules and attributes for listed DME, enteral, feeding, wheelchair and accessory items. Consolidated entries below preserve coverage status, commercial flags, typical frequency/replacement interval, quantity limits, and prior authorization indicators.

Enteral feeding supply kit; syringe fed, per day — Description: includes feeding/flushing syringe, administration set tubing, dressings, tape. Coverage: Covered (MED/SUB/CSN/RHE/RHP = Covered). Integrity: Covered. Commercial: M. Frequency/Replacement interval: 31 (monthly). Quantity: N (variable). Prior Authorization: B4034.

Enteral feeding supply kit; pump fed, per day — Description: includes feeding/flushing syringe, administration set tubing, dressings, tape. Coverage: Covered. Integrity: Covered. Commercial: M. Frequency/Replacement interval: 31 (monthly). Quantity: N. Prior Authorization: N.

Enteral feeding supply kit; gravity fed, per day — Description: includes feeding/flushing syringe, administration set tubing, dressings, tape. Coverage: Covered. Integrity: Covered. Commercial: M. Frequency/Replacement interval: M. Quantity: (not specified). Prior Authorization: N.

Nasogastric tubing with stylet — Coverage: Covered. Integrity: Covered. Commercial: M. Frequency/Replacement interval: 3 years. Quantity: N. Prior Authorization: B4081.

Nasogastric tubing without stylet — Coverage: Covered. Integrity: Covered. Commercial: M. Frequency/Replacement interval: 3 years. Quantity: N. Prior Authorization: N.

Gastrostomy/jejunostomy tube, standard — Coverage: Covered. Integrity: Covered. Commercial: Q. Frequency/Replacement interval: 1 year. Quantity: N. Prior Authorization: B4087.

Gastrostomy/jejunostomy tube, low-profile — Coverage: Covered. Integrity: Covered. Commercial: Covered. Frequency/Replacement interval: Q. Quantity: 1. Prior Authorization: N.

Food thickener, per oz — Coverage: Covered. Integrity: Covered. Commercial: Covered. Frequency/Replacement interval: M. Quantity: 300. Prior Authorization: N.

Enteral formula lines (adult/pediatric, multiple types B4149-B4162, B4150 etc.) — Coverage: Covered. Integrity: Covered. Commercial: mix (many Commercial = Covered or M). Frequency/Replacement interval: typically M. Quantity: commonly 750 (units) for nutritionally complete formulas; Prior Authorization: Y for most (various B-codes require prior auth).

Enteral nutrition infusion pump (B9002) — Coverage: Covered. Integrity: Covered. Commercial: Covered. Frequency/Replacement interval: 5 years. Quantity: 1. Prior Authorization: Y.

NOC for enteral supplies (B9998) — Coverage: Covered. Integrity: Covered. Commercial: Covered. Frequency: N/A. Quantity: N/A. Prior Authorization: Y.

Home glucose disposable monitor (A9275) — Coverage: Noncovered (MED/Sub integrity = Covered). Commercial: Noncovered. Frequency: N/A. Quantity: N/A. Prior Authorization: N.

Monitoring/alert devices (A9279-A9281) — A9279 Covered (Commercial = Noncovered), Quantity 1, Prior Authorization = Y. A9280 Covered (Commercial = Noncovered), Quantity 1, Prior Authorization = Y. A9281 Covered (Commercial = Noncovered), Quantity 1, Prior Authorization = (entry truncated) typically N or Y per code.

Enteral feeding tube accessories and supplies (A4206–A4226 examples) — Syringes, needles, sterile water, flushes: Coverage = Covered; Frequency commonly M or Q; Quantities and PA flags vary (many PA = N).

Disposable supplies for ostomy and urological care (A4330–A4384, A4361–A4385 etc.) — Coverage: Generally Covered; Quantities and replacement intervals provided (eg A4330 qty 31 monthly; A4361 qty 3 bi-annual; A4384 qty 10 monthly). Prior Authorization: typically N.

Ostomy skin barriers and adhesives (A4364–A4408 series) — Coverage: Covered for most (some items Noncovered for certain payers, e.g., A4283 Noncovered for MED). Frequency: M to Y; Quantities specified (A4364 qty 4 monthly, A4405 qty 4 monthly). Prior Authorization: usually N.

Electrical stimulation / neuromodulation supplies (A4593–A4595, E0744–E0770) — Coverage: Covered for many items; quantities often 1 and PA required for higher-acuity devices (A4593 PA = Y; A4594 PA = Y; E0747/E0748/E0760 etc. often PA = Y).

Pneumatic and compression devices (A4600, E0650–E0659) — Coverage: Covered. A4600 sleeve replacement: Frequency Y (annual), Quantity 1, Prior Authorization = Y. Pneumatic compressors and appliances: Coverage = Covered; many require PA = Y.

Wheelchair accessories and seating components (E0935, E0958, E0970 and many E09xx entries) — Coverage: accessory items generally Covered; some commercial flags vary (Commercial = 5 or Noncovered for specific items). Frequency/Replacement intervals: commonly 5 years; Quantities per item provided. Prior Authorization: usually N, exceptions flagged (E0952, E0970, etc.).

Patient lifts, standing and sit-to-stand systems (E0620–E0636, E0642, E0635, E0636) — Coverage: Covered for many; commercial may be Noncovered. Many items require Prior Authorization = Y (patient lifts, standing frames, combination systems).

Beds, mattresses and pressure-reducing surfaces (E0272, E0277, E0181, E0194, E0196) — Coverage: Covered. Typical quantity 1 with replacement intervals 1–5 years depending on item. Prior Authorization: mixed (some Y for specialized items).

Prior Authorization and Documentation Highlights

Prior Authorization

Prior authorization required: A4239 (CGM)

A4239 (nonimplanted continuous glucose monitor) is marked Prior Authorization Required = Y; obtain prior authorization before dispensing.

Documentation Required

Prior authorization generally not required for most A‑codes

Most listed A‑codes in the A4xxx–A6xxx sections are Covered and have Prior Authorization Required = N; routine supplies and dressings typically do not need prior authorization.

Prior Authorization

Check per‑code PA flag (A4xxx examples)

Selected A4xxx codes have explicit PA flags in the table — examples: A4328 PA=N; A4335 PA=Y; A4336 is Noncovered (PA=N); A4405 PA=N — check the code line for the PA indicator before billing.

Prior Authorization

No PA required for ostomy barriers (A4405–A4410)

Ostomy barrier codes A4405–A4410 are listed with Prior Authorization Required = N; do not submit PA for standard ostomy barrier items in that range.

Prior Authorization

Prior authorization required for select supplies

Some specific supplies require prior authorization — examples in the A44xx–A46xx range include A4421, A4544, A4545, A4555, A4593, A4594, and A4600; verify PA before providing these items.

Documentation Required

Covered but PA required: A4421

A4421 (Ostomy supply; miscellaneous) is Covered but Prior Authorization Required = Y — obtain PA despite coverage status.

Prior Authorization

PA required for A4593 and A4594

Some HCPCS in this supply section specifically require PA — for example A4593 Prior Authorization Required = Y and A4594 Prior Authorization Required = Y; confirm PA for these codes.

Billing Rule

Most codes covered without PA; adhere to listed quantities/frequencies

The majority of dressing, bandage and many supply codes in this segment are Covered and show Prior Authorization Required = N; follow the listed quantity/frequency limits when billing.

Prior Authorization

No PA needed: A5102, A5105, A5112

Examples of codes listed with Prior Authorization Required = N include A5102, A5105, and A5112 — no PA necessary for these urinary/bedside drainage items.

Prior Authorization

No PA for listed skin/ostomy supplies (examples)

Examples of codes marked PA = N in the skin/ostomy group include A5113, A5114, A5120, A5121, A5122, A5126, and A5131 — bill per the listed quantities without PA.

Prior Authorization

PA required for wound fillers A6261 and A6262

Wound filler codes A6261 (gel/paste) and A6262 (dry form) are marked Prior Authorization Required = Y; obtain PA prior to coverage determination.

Documentation Required

No PA for most dressings and bandages

Most dressing and bandage HCPCS lines in the A62xx–A64xx range show Prior Authorization Required = N; standard dressings and gauze do not typically require PA.

Prior Authorization

Verify PA per A64xx line‑item

Certain A64xx items include mixed PA flags per code — check the code line (e.g., A6455 PA=N; A6456 PA=N) to determine if PA is required for a specific A64xx code.

Prior Authorization

Prior authorization for compression garments/wraps varies by code

Compression garment and wrap codes explicitly indicate PA per code (many custom or specialty garments marked PA = Y while some standard items are N); verify PA for garment codes before ordering.

Prior Authorization

Per‑line PA flags in A65xx range (example A6566 Y, A6568 N)

Line‑item examples show PA flags per HCPCS: A6566 Prior Authorization Required = Y; A6568 Prior Authorization Required = N — confirm the PA status for each A65xx item billed.

Prior Authorization

Specific prior authorization code references (e.g., A7000)

Some accessory entries reference a specific prior authorization code instead of Y/N (example: disposable canister lists Prior Authorization Required = A7000) — use the referenced PA code when applicable.

Prior Authorization

PA required: A7021 (chest wall oscillation vest)

A7021 (high frequency chest wall oscillation system vest replacement) is marked Prior Authorization Required = Y; obtain PA for A7021 prior to replacement billing.

Prior Authorization

PA required: A9274

A9274 (external ambulatory insulin delivery system, disposable) is listed with Prior Authorization Required = Y; secure prior authorization before dispensing.

Prior Authorization

Multiple device codes require PA (A9279, A9280, A9281, A9900, A9901, A9999)

Several HCPCS items are grouped and marked Prior Authorization Required = Y (examples include A9279, A9280, A9281, A9900, A9901, A9999); check each code's PA flag before ordering.

Prior Authorization

Confirm PA for listed HCPCS examples (enteral, tube, pump codes)

The policy lists many specific HCPCS lines that require prior authorization — providers must reference the code table entries to confirm PA (examples include B4034, B4081, B4148, B9002, E0114 listed as requiring PA).

Prior Authorization

Check PA for E‑codes (most N; some Y like E0172/E0193)

E‑code PA indicators are shown per line; most E‑codes list Prior Authorization Required = N, but specific E‑codes (e.g., E0172, E0175, E0190, E0193, E0194) are marked Y — check each E‑code for PA.

Prior Authorization

PA required: Pediatric hospital crib E0300

Pediatric hospital crib E0300 is Covered but Prior Authorization Required = Y; obtain PA prior to provision for pediatric members.

Prior Authorization

PA required for select respiratory and pediatric bed items

Several respiratory and pediatric bed items are identified as requiring prior authorization (examples: E0328, E0329, E0465, E0466, E0470, E0471, E0472) — secure PA for these higher‑acuity devices.

Documentation Required

No PA for many bed/mattress items (E02xx examples)

Most bed and mattress codes in the E02xx range are Covered and list Prior Authorization Required = N (e.g., E0272, E0275, E0290) — PA is not typically required for standard beds/mattresses.

Prior Authorization

PA required: E0470

E0470 (pressure capability respiratory assist device) is marked Prior Authorization Required = Y — obtain PA before providing this device.

Prior Authorization

Mixed PA requirements for respiratory devices (verify per code)

Respiratory devices show mixed PA requirements: E0471/E0472/E0483 are PA = Y while E0480/E0481/E0482 are PA = N — confirm PA per exact code before ordering.

Prior Authorization

PA summary: neuromuscular/oral/sleep devices vary by code

Neuromuscular/oral/sleep devices and related items show varied PA flags — multiple oral neuromuscular stimulation and sleep/apnea devices are PA = Y while others (e.g., E0500) are PA = N; verify PA per code.

Prior Authorization

PA required for many patient lifts and standing systems

Many patient lifts, seat lift mechanisms and standing systems indicate Prior Authorization Required = Y (examples: patient lift bathroom/toilet, seat lift mechanism, E0635, standing frame/table systems) — obtain PA for lift/standing equipment.

Prior Authorization

Prior authorization required for fixed patient lift and standing systems

Selected examples list PA = Y for patient lift fixed systems and standing frame/table systems — do not proceed without prior authorization for these complex mobility systems.

Prior Authorization

PA required for pneumatic compressors (E0642, E0650–E0652)

Pneumatic compressor family shows PA = Y for E0642 and E0650/E0651/E0652 — obtain PA for these pneumatic compressor devices and segmental/non‑segmental home models.

Prior Authorization

Examples with no PA: E0670, E0677, E0679

Examples of E‑codes with Prior Authorization Required = N include E0670, E0677, and E0679 — these nonpneumatic compression and related items typically do not require PA.

Prior Authorization

PA status varied for infusion pump codes (E0770 Y; E0784 Y; E0787/E0791 N)

Sample HCPCS entries show mixed PA status: E0770 and E0784 list Prior Authorization Required = Y while E0787 and E0791 list PA = N — validate PA per line before billing infusion pumps and related equipment.

Prior Authorization

PA cross‑references for accessories (e.g., E0952, E0970)

Some wheelchair and accessory entries reference required prior authorization codes for accessories (examples: E0952 and E0970 are cited as PA cross‑references); use the referenced PA code when submitting authorization requests for accessories/footplates.

Table Keys, Flags and Frequency Codes

Prior Authorization Required

Prior Authorization Required (definition)Indicator showing whether prior authorization is required for the specific HCPCS code (Y = yes, N = no)

A4239 (example)A4239 prior authorization required = Y (nonimplanted CGM)

Most A-codesMajority of listed A-codes indicate Prior Authorization Required = N

Frequency codes

Frequency codes (definitions)M = Monthly; Q = Quarterly; B = Bi-annual; Y = Annual; 2-5 = Years

Example — NebulizerChunk shows 2-5 = Years = 3 for certain nebulizer items

UsageFrequency abbreviations used throughout per-code entries

Frequency codes (table usage)

Frequency abbreviations in tableM = Monthly; Q = Quarterly; B = Bi-annual; Y = Annual; 2-5 = Years

Bi-annual (B)Used for some items (e.g., A4361 Quantity=3, Frequency=B)

Numeric years2-5 used to indicate multi-year replacement interval (commonly 5)

Coverage status terms

Coverage status termsEntries indicate Covered or Noncovered and include PA flag Y/N per line

A4336 exampleA4336 is Noncovered (Commercial Noncovered) per chunk

Most itemsMost listed items are Covered with PA noted when required

Frequency abbreviations

Frequency abbreviations (explanation)M = Monthly; Q = Quarterly; B = Bi-annual; Y = Annual; 2-5 = Years

ApplicationUsed in per-code lines to indicate refill/replacement intervals

N/AShown where not applicable for quantity/frequency

Prior Authorization flag

Prior Authorization flag (Y/N)Indicates Y = prior authorization required; N = not required for the HCPCS code

A4593/A4594Example: A4593 and A4594 show PA = Y (neuromodulation items)

Most dressing codesMost dressing and bandage codes show PA = N

Prior Authorization Required (Y/N) — meaning

PA indicates code-level requirementPrior Authorization Required (Y/N) indicates whether PA is required for the HCPCS code

A4421A4421 is Covered but PA = Y (misc ostomy supply)

Most A5–A51 entriesMany entries in these ranges have PA = N

Frequency indicators (M/Q/B/Y/2-5)

Frequency codes used (repeat)M/Q/B/Y/2-5 appear throughout per-code table to indicate monthly, quarterly, bi-annual, annual, multi-year intervals

Replacement examples2-5 often corresponds to 5 years for replacement

Rental indicatorM can indicate monthly rental for equipment lines

Frequency abbreviations used in table

Frequency abbreviations (table)M = Monthly; Q = Quarterly; B = Bi-annual; Y = Annual; 2-5 = Years

Shown per-codeEach HCPCS line uses these abbreviations to show allowed intervals

N/A usageN/A used where frequency not applicable

Prior authorization flag — PA = N meaning

PA = N examplePA = N indicates no prior authorization required for that code (e.g., A5102, A5105, A5112)

Most supply itemsMany supply codes show PA = N

ExceptionsSelected items (e.g., A4593, A4594) do require PA = Y

Frequency codes — multi-year (2-5)

Frequency code definitions (years)2-5 = Years used to express replacement or review interval (commonly resolves to 5 years)

E0770Frequency = 2-5 = 5 years; Quantity = 1; PA = Y

E0149Frequency = 2-5 = 5 years; Quantity = 1; PA = N

Prior Authorization flag — PA = Y meaning

PA = Y meaningPA = Y indicates prior authorization required for the HCPCS code (pre-service authorization)

ExamplesA4239 (CGM) and E0770 (infusion pump) list PA = Y

Provider actionSubmit pre-service prior authorization when PA = Y per code guidance

Enteral feeding supply kit (syringe fed) — definition and included items

Enteral feeding supply kit — syringe fedDefinition: per day kit includes feeding/flushing syringe, administration set tubing, dressings, tape; Frequency indicator = 31 (per day); PA reference = B4034

Pump/gravity fed kitsAlso defined per day and include similar components; Frequency indicator = 31; PA varies by kit type

Commercial noteCommercial column often marked M for enteral kits

Enteral feeding supply kit (pump/gravity fed)

Enteral feeding supply kit — pump/gravity fedPer day kit includes feeding/flushing syringe, administration set tubing, dressings, tape; Frequency indicator = 31; PA = N for pump-fed per chunk

B4148Elastomeric control-fed kit: Quantity = 30; Frequency = M; PA = Y

B4149–B4162Enteral formulas: Quantity = 750 units; Frequency = M; PA = Y

Frequency codes — key

Frequency codes (concise)M = Monthly; Q = Quarterly; B = Bi-annual; Y = Annual; 2-5 = Years

Use in tableApplied per HCPCS line to show allowed refill/replacement intervals

Interpretation2-5 typically maps to 5 years unless otherwise noted

Enteral formula unit definitions

Enteral formula unit definitions100 calories = 1 unit (for many B41xx items); 500 ml = 1 unit for some formulas; typical monthly quantities shown as units (e.g., 750)

B4149/B4150100 calories = 1 unit; Quantity = 750 units/month; PA = Y

Provider implicationUnits used for enteral formula claims; convert per documentation when billing

Prior Authorization Required for E-codes

PA for E-codesIndicates whether pre-service authorization is required for the listed E-code (Y or N shown per line)

ExamplesE0770 PA = Y; E0776 PA = N; many E0xx show PA flags per chunk

ActionFollow code-specific PA requirements when submitting claims for E-codes

Replacement or expected frequency (definitions)

Replacement intervals (definition)Replacement/expected frequency indicated as M (monthly), Q (quarterly), B (bi-annual), Y (annual), or numeric years (2-5) — numeric years commonly interpreted as 5

ExamplesE0149 replacement interval = 2-5 = 5 years; E0272 = 2 years per chunk

ImplicationUse interval to determine eligibility for replacements/renewals

M (rental) — indicator

M (rental) indicatorM indicates monthly rental frequency for equipment where denoted (e.g., oxygen system rentals E0424, E0431)

E0424Stationary compressed gaseous oxygen system — rental; Frequency = M; Quantity = 1; PA = N

E0433Portable liquid oxygen system — rental; Frequency = M; Quantity = 1; PA = N

2-5 (Years) — interpretation

2-5 (Years) interpretationIndicates replacement/review interval expressed in years (commonly 5 years for many items)

ExamplesE0277, E0650, E0651 show 2-5 = 5 years in chunks

Provider noteUse 2-5 fields to plan replacement timing and claims

Frequency codes — quick reference

Frequency codes (summary)M = Monthly; Q = Quarterly; B = Bi-annual; Y = Annual; 2-5 = Years

UsageApplied across HCPCS lines to indicate quantity refill/replace intervals

N/AUsed when frequency not applicable

Quantity — definition and usage

Quantity (definition)Number of units allowed (commonly 1); 'N/A' indicates not applicable or not specified

ExamplesMany items list Quantity = 1 (e.g., E0470, E0290); supplies show larger numeric quantities per month (e.g., A4332 = 150)

Billing implicationUse per-code quantity when submitting claims to ensure within allowed limits

Quantity — common values

Quantity typicalNumber of units allowed commonly = 1 unless otherwise listed; supply codes list monthly quantities

ExamplesA5102/A5105/A5112 show Quantity = 1; A5051 shows Quantity = 60/month

N/A usageSome items list Quantity = N/A when not applicable

Prior Authorization per HCPCS line-item

PA per code (Y/N)Indicates whether prior authorization is required for the HCPCS line-item (Y = yes; N = no); some items reference specific PA codes (e.g., A7000)

ExamplesA4593 = Y; A4595 = N; A6261/A6262 = Y

ActionWhen PA = Y, follow prior authorization process and reference any specific PA code noted

Frequency codes (M/Q/B/Y) — E-code examples

Frequency codes (M/Q/B/Y)M = Monthly; Q = Quarterly; B = Bi-annual; Y = Annual — used in many E-code entries

E0776IV pole — Quantity = 1; Frequency = 2-5 = 5 years; PA = N

E0784External ambulatory infusion pump, insulin — Quantity = 1; Frequency = 2-5 = 5 years; PA = Y

Quantity / replacement interval — summary

Quantity / replacement intervalQuantity and replacement intervals are specified per HCPCS line item (e.g., Quantity = 1; 2-5 = Years = 5) — follow per-code fields

ExamplesE0770 Quantity = 1; Frequency = 2-5 = 5 years; PA = Y

Wheelchair accessoriesQuantities vary (often 1–2); replacement intervals commonly 5 years

OpenPayer

Durable Medical Equipment (DME) HCPCS coverage and prior authorization summary

Per-HCPCS Coverage Determinations and Limits

HCPCS Code Groups and Lists

Prior Authorization and Documentation Highlights

Table Keys, Flags and Frequency Codes