Neighborhood Health Plan RI DME A-code Coverage & PA

Per-HCPCS Coverage Criteria and Limits

Per-code coverage nodes (sample)

Per-HCPCS code coverage and limits (excerpt):

A4212 — Covered; Quantity = 100; Frequency = M (monthly); Prior Authorization Required = N

A4213 — Covered; Quantity = 30; Frequency = M (monthly); Prior Authorization Required = N

A4238 — Covered; Quantity = 1; Frequency = M (monthly); Prior Authorization Required = N

Per-code coverage entries from document excerpt

Per-code coverage entries (examples) include coverage status across plan lines, a frequency code, quantity limit, and prior authorization requirement.

A4332 — Covered; Quantity = 150; Frequency = M (monthly); Prior Authorization Required = N

A4349 — Covered; Quantity = 35; Frequency = M (monthly); Prior Authorization Required = N

A4351 — Covered; Quantity = 150; Frequency = M (monthly); Prior Authorization Required = N

A4336 — Noncovered; Quantity = N/A; Frequency = N/A; Prior Authorization Required = N

A4368 — Covered; Quantity = 60; Frequency = M (monthly); Prior Authorization Required = N

Ostomy skin barriers and related supplies (sample)

Codes listed as Covered with specified quantity, frequency, and prior authorization status.

A4405 — Ostomy skin barrier, non-pectin based, paste, per ounce; Covered; Frequency = M (monthly); Quantity = (unspecified in table); Prior Authorization Required = N

A4406 — Ostomy skin barrier, pectin-based, paste, per ounce; Covered; Frequency = M (monthly); Quantity = 4 per month; Prior Authorization Required = N

A4407 — Ostomy skin barrier with flange, extended wear; Covered; Frequency = M (monthly); Quantity = 20 per month; Prior Authorization Required = N

Ostomy pouches (examples)

Ostomy pouches and accessories listed with coverage and monthly quantity limits.

A4416 — Ostomy pouch, closed, with barrier attached, with filter (1 piece); Covered; Quantity = 60 per month; Frequency = M (monthly); Prior Authorization Required = N

A4424 — Ostomy pouch, drainable, with barrier; Covered; Quantity = 20 per month; Frequency = M (monthly); Prior Authorization Required = N

A4422 — Product to thicken liquid stomal output (sheet/pad/crystal packet); Covered; Quantity = 60 per month; Frequency = M (monthly); Prior Authorization Required = N

Miscellaneous supplies and devices

Select non-ostomy supplies and neuromodulation accessory codes.

A4542 — Supplies and accessories for external upper limb tremor stimulator; Covered; Prior Authorization Required = Y

A4543 — Supplies for transcutaneous electrical nerve stimulator (auricular region), per month; Covered; Prior Authorization Required = (blank/unspecified)

A4595 — Electrical stimulator supplies, 2 lead, per month; Covered; Quantity = 2 per month; Frequency = M (monthly); Prior Authorization Required = N

A4605 — Tracheal suction catheter; closed system, each; Covered; Quantity = 90; Frequency = M (monthly); Prior Authorization Required = N

Per-code coverage entries (JSON-encoded nodes)

Per-HCPCS coverage entries in this section

A4595 — Covered; Quantity = 2 per month; Prior Authorization Required = N

A4600 — Covered; Quantity = (not specified); Prior Authorization Required = (not specified)

A4602 — Replacement battery for external infusion pump; Covered; Frequency = B (bi-annual); Quantity = 18; Prior Authorization Required = N

A4614 — Peak expiratory flow rate meter; Covered; Frequency = 3 years; Quantity = 1; Prior Authorization Required = N

A4616 — Tubing (oxygen), per foot; Covered; Quantity = 200; Prior Authorization Required = N

A4623 — Tracheostomy inner cannula; Covered; Quantity = 62 per month; Prior Authorization Required = N

Per-code coverage criteria (sample rows)

Per-code coverage entries (examples shown below).

A5113 — Strap; latex, replacement only, per set leg; Covered; Quantity = 2; Frequency = M (monthly); Prior Authorization Required = N

A5120 — Skin barrier or swabs; Covered; Quantity = 150; Frequency = B (bi-annual); Prior Authorization Required = N

A5501 — Custom molded shoe, per shoe (for diabetics only); Covered; Quantity = 2; Prior Authorization Required = N

A6216 — Gauze, non-impregnated, non-sterile, size 16 sq in or less; Covered; Quantity = 90; Frequency = M (monthly); Prior Authorization Required = N

Covered items with limits

Items listed below are designated Covered with specified quantity and frequency limits; most do not require prior authorization.

A6232 — Gauze impregnated, hydrogel; Covered; Quantity = 31 per month; Prior Authorization Required = N

A6234 — Hydrocolloid dressing, 16 sq in; Covered; Quantity = 12 per month; Prior Authorization Required = N

A6248 — (listed wound care item) — Covered; Quantity = 3 per month; Prior Authorization Required = N

A6257 — Transparent film, sterile, 16 sq in or less; Covered; Quantity = 180; Frequency = B (bi-annual); Prior Authorization Required = N

A6402 — (example) Covered; Quantity = 93 per month; Prior Authorization Required = N

Per-code coverage examples

Per-code coverage entries included below indicate whether the item is covered, typical quantity limits, frequency, and prior authorization requirement when specified.

A6457 — Tubular dressing, any width, per linear yard; Covered; Quantity = 50 per month; Prior Authorization Required = N

A6501 — Compression burn garment; Covered; Quantity = 8 (4 Left/4 Right); Prior Authorization Required = N

A6512 — Compression burn garment not otherwise classified; Covered; Quantity = 16 (8 Left/8 Right); Prior Authorization Required = (blank)

A6550 — Wound care set for negative pressure wound therapy; Covered; Quantity = 15 per month; Prior Authorization Required = N

A6530 — Gradient compression garment, knee; Covered; Quantity = 16 (8 Left/8 Right); Prior Authorization Required = N

Compression garments and wraps

Entries show coverage status and limits for gradient compression items

Gradient compression garments and custom variants — Covered; common quantity = 3; common frequency = B (bi-annual) or as indicated; Prior Authorization = varies (Y/N/blank)

Bandaging supplies

Bandaging supplies and padding

Compression bandaging supplies (tubular dressings, bandage rolls, liners) — Covered; Frequency and quantity vary (many items show N/A or specified quantities); Prior Authorization = varies (some Y, many N or blank)

Suction and nebulizer supplies

Suction pump and nebulizer supplies

Suction pump canister, disposable — Covered; Frequency example = 10 years shown; Prior Authorization Required = A7000 (authorization code reference)

Suction pump canister, non-disposable — Covered; Frequency = 2 years; Quantity = 1; Prior Authorization Required = N

Administration set with small volume nonfiltered pneumatic nebulizer, disposable — Covered; Quantity = 2 per month; Prior Authorization Required = N

Water, distilled, used with large volume nebulizer — Covered; Quantity = 56 per month; Prior Authorization Required = N

Itemized coverage criteria

Per-item coverage statements and limits

A7028 — Combination oral/nasal mask; Covered; Quantity = 1; Frequency = M (monthly); Prior Authorization Required = N

High frequency chest wall oscillation system vest — Covered; Replacement frequency = 3 years; Prior Authorization Required = N

A7033 — Pillow for cannula interface replacement; Covered; Quantity = 6 per month; Prior Authorization Required = N

Filter, disposable for positive airway device — Covered; Quantity = 6 per month; Prior Authorization Required = N

A7504 — Filter for tracheostoma HME system; Covered; Quantity = 62 per month; Prior Authorization Required = N

A9275 — Home glucose disposable monitor, includes test strips — Noncovered (Commercial = Noncovered); Prior Authorization Required = N

Coverage items and concise criteria

Items listed in this section are shown with coverage status, frequency, quantity, commercial tier, integrity, and prior authorization requirements where applicable.

Enteral supply kit - syringe fed — Covered; Frequency = 31 per month; Prior Authorization Required = B4034

Enteral feeding supply kit - pump fed — Covered; Prior Authorization Required = N

Enteral supply kit - gravity fed — Covered; Frequency = M (monthly); Prior Authorization Required = N

Enteral formulas (B4149-B4162) — Covered; Typical quantity = 750 units/month; Some specific formulas require prior authorization (e.g., B4102)

Enteral nutrition infusion pump (B9002) — Covered; Replacement frequency = 5 years

Per-HCPCS coverage nodes (JSON-encoded)

Per-item coverage stance and limits (partial extract):

E0144 — Walker; Covered; Prior Authorization Required = N

E0149 — Walker; heavy duty; Covered; Replacement interval = 5 years; Prior Authorization Required = N

E0160 — Sitz type bath/equipment; Covered for many lines; Commercial = Noncovered; Replacement interval = 5 years; Prior Authorization Required = N

E019O (E0197) — Air pressure mattress pad; Covered; Replacement interval = 3 years; Prior Authorization Required = N

E0255 — Hospital bed, fixed height with mattress; Covered; Replacement interval = 5 years; Quantity = 1; Prior Authorization Required = N

Hospital beds

Hospital beds and related accessories — general coverage and limits shown per HCPCS code:

E0255 — Hospital bed; Covered; Frequency = Years=5; Quantity = 1; Prior Authorization Required = N

E0256 — Hospital bed, variable height (hi-lo) without mattress; Covered; Frequency = Years=5; Prior Authorization Required = N

E0260 — Hospital bed, semi-electric with mattress; Covered; Frequency = Years=5; Prior Authorization Required = N

E0261 — Hospital bed, semi-electric without mattress; Covered; Frequency = Years=5; Quantity = 1; Prior Authorization Required = N

Mattresses and bed accessories

Mattresses, overlays, and bed accessories — coverage and renewal frequency:

E0272 — (sample mattress/overlay) Covered; Frequency = Years=2; Quantity = 1; Prior Authorization Required = N

E0277 — Powered pressure-reducing air mattress; Covered; Frequency = Years=5; Prior Authorization Required = N

E0280 — Bed cradle; Covered; Frequency = Years=5; Prior Authorization Required = N

Oxygen systems and accessories

Oxygen equipment, contents, and monitoring devices — coverage and supply definitions:

E0424 — Stationary compressed gaseous oxygen system, rental; Covered; Frequency = M (monthly); Prior Authorization Required = N

E0431 — Portable gaseous oxygen system, rental; Covered; Frequency = M (monthly); Quantity = 1; Prior Authorization Required = N

E0445 — Oximeter device for measuring blood oxygen non-invasively; Covered; Frequency = Years=3; Quantity = 1; Prior Authorization Required = N

E0441 — Stationary oxygen contents, gaseous; Covered; 1 month's supply = 1 unit; Prior Authorization Required = N

Pressure management devices and ventilators

Pressure management and ventilators — coverage and prior authorization where indicated:

E0372 — Powered air overlay for mattress; Covered; Frequency = Years=5; Prior Authorization Required = Y

E0465 — Home ventilator used with invasive interface; Covered; Quantity = 1; Frequency = M (monthly indicated); Prior Authorization Required = Y

E0467 — Home ventilator; multi-function respiratory device; Covered; Prior Authorization Required = N

Per-code coverage entries

Per-code coverage, quantity, frequency, and prior authorization fields as listed.

E0465 — Covered; Quantity = 1; Frequency indicated (M/Q/B/Y/2-5 as applicable); Prior Authorization Required = Y

E0466 — Covered; Quantity = 1; Frequency = M; Prior Authorization = (unspecified)

E0467 — Covered; Frequency = M; Prior Authorization Required = N

E0471 — Covered; Quantity = 1; Frequency = Years=5; Prior Authorization = (unspecified)

E0480 — Percussor; Covered; Quantity = 1; Frequency = Years=5; Prior Authorization Required = N

E0481 — Intrapulmonary percussive ventilation system; Covered; Prior Authorization Required = N

Standers / sit-to-stand

Standers and sit-to-stand systems

E0636 — Combination sit-to-stand frame/table system; Covered for MED/SUB/CSN/RHE/RHP; Integrity = Noncovered; Commercial = Noncovered in many entries; Frequency = (commonly 5 years); Quantity and PA flags vary (E0636 flag present)

Standing frame/table system — Covered; Commercial often Noncovered; Frequency = Years=5; Prior Authorization Required = (varies)

Patient lifts

Patient lift; moveable from room to room with disassembly and reassembly — Covered; Quantity = 1; Frequency = Years=5; Prior Authorization Required = Y; Commercial = Noncovered in many entries

Patient lift; fixed system — Covered; Quantity = 1; Frequency = Years=1; Prior Authorization Required = (not listed)

Pneumatic compression

Pneumatic compression devices and accessories

E0650-E0679 series — Pneumatic compressors and appliances; Covered; Typical replacement frequency = Years=5; Quantity typically = 1; Prior Authorization Required = (generally not required or blank)

Segmental pneumatic appliance examples (E0667, E0669, E0670) — Covered; Frequency = Years=5; Quantity = 1 where specified; Prior Authorization = (varies)

UV therapy systems

Ultraviolet therapy systems and other devices

Ultraviolet light therapy systems (panels, cabinets) — Covered; Frequency/replacement commonly = Years=5; Prior Authorization = (not listed)

E0694 — Therapy system in 6 foot cabinet; Covered; Frequency = Years=5; Prior Authorization = (not listed)

Electrotherapy and stimulators

Electrotherapy, neuromuscular, and stimulation devices

E0720-E0770 (TENS/neuromuscular/osteogenesis stimulator family) — Covered; Typical replacement frequency = Years=5; Quantity commonly = 1 where specified; Prior Authorization = mixed (examples: E0721 = Y, E0730 = N, E0748 = Y, E0760 = Y, E0762 = (blank))

A4252 / E0734 / E0736 etc. — Covered; Prior Authorization flags vary by code (some Y, some N, some blank)

DME coverage items (partial list)

Coverage and constraints for listed DME items

E0748 — Osteogenesis stimulator (spinal applications); Covered; Quantity = 1; Frequency = Years=5; Prior Authorization Required = Y

E0760 — Osteogenesis stimulator, low intensity ultrasound; Covered; Quantity = 1; Frequency = Years=5; Prior Authorization Required = Y

E0762 — Transcutaneous electrical joint stimulation device system; Covered; Quantity = 1; Frequency = Years=5; Prior Authorization = (blank)

E0765 — FDA-approved nerve stimulator for nausea/vomiting; Covered; Prior Authorization Required = N

E0791 / wheelchair accessories — Covered; Frequency typically = Years=5; Prior Authorization Required = N

HCPCS A-code Listing and Code Groups

Included HCPCS A-codes (sample group)HCPCSCovered

A4334	(See policy) - included in ostomy/collection supplies
A4402	(See policy) - ostomy skin barrier / related
A6566	Gradient compression garment; neck/head_each
A6567	Gradient compression garment; neck/head, custom, each
A6568	Gradient compression garment, torso and shoulder; each
A6569	Gradient compression garment; torso / shoulder; custom; each
A6570	Gradient compression garment; region, genital each
A6571	Gradient compression garment; region, custom, genital each
A6572	Gradient compression garment; toe caps, each
A6573	Gradient compression garment; toe caps, custom, each

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Ostomy and Related Supplies (sample)HCPCSCovered

A4330	Perianal fecal collection pouch with adhesive, each
A4331	Extension drainage tubing, any type, any length
A4332	Lubricant, individual sterile packet; each
A4333	Urinary catheter anchoring device, adhesive skin attachment; each
A4405	Ostomy skin barrier, non-pectin based, paste, per ounce
A4406	Ostomy skin barrier, pectin-based, paste, per ounce
A4407	Ostomy skin barrier; with flange, extended wear; built-in convexity, <=4x4 inches
A4408	Ostomy skin barrier; with flange, extended wear; built-in convexity, >4x4 inches
A4411	(Sample) ostomy-related item
A4412	Ostomy pouch, drainable, high output; for use on a barrier with flange, without filter

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Other A65xx Series (compression & bandaging)HCPCSCovered

A6566-A6611	Gradient compression & related supplies series (A65xx) - includes A6566 through A6611 as represented in policy
A6594	Gradient compression bandaging supply, bandage liner; lower extremity
A6595	Gradient compression bandaging supply, bandage liner; upper extremity

CPAP / Positive Airway Pressure SuppliesHCPCSCovered

A7000	Canister, disposable, used with suction pump (policy references A7000)
A7020	(Policy) sample CPAP/humidification accessory
A7021	(Policy) CPAP accessory - representative of series
A7029	Nasal pillows for combination oral/nasal mask, replacement only, pair
A7030	Full face mask used with positive airway pressure device, each
A7031	Face mask interface, replacement for full face mask; each
A7032	Cushion for use on nasal mask interface, replacement only, each
A7033	Pillow for use On cannula type interface, replacement only, nasal pair
A7034	Nasal interface (mask Or cannula type) used with positive airway pressure device
A7035	Headgear used with positive airway pressure device

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Selected Respiratory and Monitoring E-codesHCPCSCovered

E0550	Humidifier, durable for extensive supplemental humidification
E0561	Humidifier; non-heated, used with positive airway pressure device
E0565	Compressor, air power source for equipment which is not self-contained
E0570	Nebulizer; with compressor
E0603	Breast pump, electric (ac and/or dc), any type
E0604	Breast pump, hospital grade, electric (ac and or dc)
E0610	Pacemaker monitor; self-contained
E0618	Apnea monitor; without recording feature
E0635	Patient lift, electric with seat Or sling
E0766	Electrical stimulation device used for cancer treatment

E06xx / E07xx Series (respiratory, compression, stim)HCPCSCovered

E0650-E0679	Pneumatic compression device series (E0650 through E0679) represented in policy
E0720-E0770	Electrical stimulation and related device series (E0720 through E0770) represented in policy
E0766	Electrical stimulation device used for cancer treatment, includes all accessories
E0770	Functional electrical stimulator, transcutaneous stimulation complete system

Additional DME and Accessories (representative)HCPCSCovered

E0441	Stationary oxygen contents, gaseous, 1 month's supply = 1 unit
E0465	(Sample) oximeter device related listing
E0635	Patient lift, electric with seat Or sling
E0705	Transfer device, any type, each
E0720	TENS device; two lead, localized stimulation

Prior Authorization and Billing Actions for Providers

Prior Authorization

Prior Authorization Summary (consolidated)

Prior authorization (PA) requirements vary by HCPCS/A-code and item type. Some listed A‑codes and select supplies do NOT require PA, while others require PA or are flagged to a specific authorization code. Verify PA status for each code before ordering.

General excerpt: many A‑codes (e.g., A4206–A4212 series, A4328, A4330–A4333, A4335–A4341, A4355–A4358, A4405–A4408, A4483, A4541) show 'Prior Authorization Required = N' or blank indicating no PA for standard members.
Prior authorization summary for listed A‑codes: specific A‑codes with explicit PA = Y include A4542 (supplies for external upper limb tremor stimulator) and A6567/A6569 (custom gradient compression garments). Several A‑codes show explicit authorization codes rather than simple Y/N (see items below).
Select supplies: many enteral and ostomy supplies list no PA (e.g., A4328, A4332, A4355, A5113–A5121, A6232–A6235), but certain supply kits and pump‑related supplies require PA (see B‑series mappings).
PA notes for HCPCS items: where a specific authorization code is required, the code is shown in the prior authorization field (for example: suction canister = A7000; enteral supply kits and formulas map to B‑codes).
Prior authorization summary for listed A‑codes (repeat check): confirm codes with blank PA fields — blanks may indicate not applicable or internal review; treat explicit 'N' as no PA required and explicit 'Y' or an authorization code as PA required.
Prior authorization indicators for HCPCS: many E‑ and A‑series items include explicit Y/N or code mapping (e.g., E019O = Y; E0144 = N; E0445 = N).

Definitions, Frequency Codes, and Field Keys

A4239 (CGM)

A4239 (CGM) definitionNonimplanted continuous glucose monitor (CGM), includes all sensors and accessories; 1 month supply = 1 supplies

Coverage statusA4239 = Covered; Frequency field appears but quantity unspecified in excerpt

Prior AuthorizationA4239 Prior Authorization field = . (blank) in source

Frequency code key

MMonthly

QQuarterly

BBi-annual

OpenPayer

Durable Medical Equipment (DME) HCPCS A-code reimbursement/payment catalogue

Per-HCPCS Coverage Criteria and Limits

HCPCS A-code Listing and Code Groups

Prior Authorization and Billing Actions for Providers

Definitions, Frequency Codes, and Field Keys