CurrentUnitedHealthcarePolicy N/A

Empire Plan Durable Medical Equipment (DME) Notification List For Members with Primary Empire Plan Coverage

Lists DME/HCPCS codes that require prior notification to The Empire Plan Home Care Advocacy Program (HCAP) for members with The Empire Plan as primary coverage; failure to notify prior to delivery will result in no payment except in emergencies.

Policy Summary

PayerUnitedHealthcare

PolicyEmpire Plan Durable Medical Equipment (DME) Notification List

Policy CodePolicy N/A

Change TypeAdministrative — no material coverage changes

Effective DateJanuary 1, 2025

Next Review DateN/A

Key ActionNotify HCAP via the UnitedHealthcare Provider Portal or by phone at 1-877-769-7447 prior to delivery for listed DME items to avoid denial of payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+HCPCS/DME codes listed requiring notification

1Required notification program (HCAP)

2Notification methods

S1034Artificial pancreas device code present

Coverage & Notification Requirements

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.

Notification-based coverage criteria

Covered when ALL of the following are met:

Notify HCAP prior to delivery for listed DME items for members with The Empire Plan as primary coverage

Notifications may be submitted via the UnitedHealthcare Provider Portal (uhcprovider.com) or by phone at 1-877-769-7447 (Select Medical Program → Benefits Management Program → Durable Medical Equipment)

Failure to notify HCAP prior to delivery will result in no payment for the item, except in the case of an emergency

Code listing — informational

The following HCPCS/K/S codes and descriptions are listed for items that require notification (informational; no additional clinical criteria provided here):

Sample codes (excerpt)

A4226 - Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week (For Type 2 diabetes only)
A4238 - Supply allowance for adjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit
A4239 - Supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit

Additional DME examples (excerpt)

E0265 - Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress
E0483 - High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each
E0784 - External ambulatory infusion pump, insulin

Power wheelchair and related K-codes (excerpt)

K0858 - Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0859 - Power wheelchair, group 3 heavy duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds
K0860 - Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0861 - Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0862 - Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

Additional K- and device codes (excerpt)

K0878 - Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds
K0879 - Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0880 - Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0884 - Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0885 - Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds

Miscellaneous device and S-/K- codes (excerpt)

K1018 - External upper limb tremor stimulator of the peripheral nerves of the wrist
K1019 - Monthly supplies for use of device coded at K1018
S1030 - Continuous noninvasive glucose monitoring device, purchase
S1031 - Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor
S1034 - Artificial Pancreas Device System (includes Continuous Glucose Monitor, Blood Glucose Device, Insulin Pump, and Computer Algorithm)
S1035 - Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system

HCPCS / DME Codes Requiring Notification

Sample DME/HCPCS codes requiring notificationHCPCSCovered

A4226	Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week (For Type 2 diabetes only)
A4238	Supply allowance for adjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service
A4239	Supply allowance for nonadjunctive, nonimplanted continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service

Additional DME/HCPCS codes requiring notificationHCPCSCovered

E0265	Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress
E0483	High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each
E0784	External ambulatory infusion pump, insulin

Power wheelchair K-codes (excerpt) — Group 3-5 examplesHCPCSCovered

K0858	Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0859	Power wheelchair, group 3 heavy duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds
K0860	Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0861	Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0862	Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0863	Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0864	Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more
K0868	Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0869	Power wheelchair, group 4 standard, captain's chair, patient weight capacity up to and including 300 pounds
K0870	Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

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Additional K-codes and device codes (excerpt)HCPCSCovered

K0878	Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds
K0879	Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0880	Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
K0884	Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0885	Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds
K0886	Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
K0890	Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0891	Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0898	Power wheelchair, not otherwise classified
K0899	Power mobility device, not coded by DME PDAC or does not meet criteria

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S- and K- codes for miscellaneous devices — device/supply codesHCPCSCovered

K1018	External upper limb tremor stimulator of the peripheral nerves of the wrist
K1019	Monthly supplies for use of device coded at K1018
S1030	Continuous noninvasive glucose monitoring device, purchase
S1031	Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor
S1034	Artificial Pancreas Device System (e.g., Low Glucose Suspend [LGS] feature) including Continuous Glucose Monitor, Blood Glucose Device, Insulin Pump, and Computer Algorithm that communicates with all of the Devices
S1035	Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system
S1036	Transmitter; external, for use with artificial pancreas device system
S1037	Receiver (monitor), external, for use with artificial pancreas device system
S8130	Interferential current stimulator, 2 channel
S8131	Interferential current stimulator, 4 channel

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CGM supply unit definition

DefinitionContinuous glucose monitor (CGM) supply allowance: 1 month supply = 1 unit of service (applies to A4238 and A4239).

Codes referencing definitionA4238: adjunctive nonimplanted CGM supply; A4239: nonadjunctive nonimplanted CGM supply.

ScopeIncludes all supplies and accessories associated with the listed CGM HCPCS codes.

Enteral formula unit definition

Enteral formula unit (adult/pediatric clear liquids)500 ml = 1 unit (applies to B4102 and B4103).

Enteral formula unit (manufactured blenderized)100 calories = 1 unit (applies to B4149).

Related supply codesB4034, B4035, B4036 — enteral feeding supply kits referenced in the same section.

Patient weight capacities (by code)

Up to and including 125 poundsCodes K0890 and K0891 — Power wheelchair, group 5 pediatric, patient weight capacity up to and including 125 pounds.

Up to and including 300 poundsMultiple codes (e.g., K0861, K0868, K0869, K0871, K0878, K0884, K0885) — patient weight capacity up to and including 300 pounds.

301 to 450 poundsMultiple codes (e.g., K0858, K0859, K0862, K0870, K0886, K0879) — patient weight capacity 301 to 450 pounds.

451 to 600 poundsCodes such as K0860, K0863, K0880 — patient weight capacity 451 to 600 pounds.

601 pounds or moreK0864 — patient weight capacity 601 pounds or more.

What Providers Must Do

Prior Authorization

HCAP Notification Required

The Empire Plan Durable Medical Equipment (DME) Notification List for members with primary Empire Plan coverage requires notification to The Empire Plan Home Care Advocacy Program (HCAP) prior to delivery. Failure to notify HCAP before delivery will result in no payment for the item, except in the case of an emergency.

Notification can be made via uhcprovider.com using the UnitedHealthcare Provider Portal
Or by calling 1-877-7-NYSHIP (1-877-769-7447): Select Medical Program → Benefits Management Program → Durable Medical Equipment

Billing Rule

Power Wheelchair Group Codes (partial list)

The following power wheelchair (K-code) group codes require HCAP notification prior to delivery for members with primary Empire Plan coverage.

K0858 — Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301–450 pounds
K0859 — Power wheelchair, group 3 heavy duty, single power option, captain's chair, patient weight capacity 301–450 pounds
K0860 — Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451–600 pounds
K0861 — Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0862 — Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301–450 pounds
K0863 — Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451–600 pounds
K0864 — Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more
K0868 — Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0869 — Power wheelchair, group 4 standard, captain's chair, patient weight capacity up to and including 300 pounds
K0870 — Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301–450 pounds
K0871 — Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0878 — Power wheelchair, group 4 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds

Billing Rule

Power Wheelchair & Related DME Codes (partial list)

Additional power wheelchair and related DME codes that require HCAP notification prior to delivery include the following.

K0879 — Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301–450 pounds
K0880 — Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451–600 pounds
K0884 — Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0885 — Power wheelchair, group 4 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds
K0886 — Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301–450 pounds
K0890 — Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0891 — Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0898 — Power wheelchair, not otherwise classified
K0899 — Power mobility device, not coded by DME PDAC or does not meet criteria
K0900 — Customized durable medical equipment, other than wheelchair
K1004 — Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories

Billing Rule

Miscellaneous Device and Supply Codes (partial list)

The following miscellaneous device and supply codes also require HCAP notification prior to delivery for members with primary Empire Plan coverage.

K1018 — External upper limb tremor stimulator of the peripheral nerves of the wrist
K1019 — Monthly supplies for use of device coded at K1018
S1030 — Continuous noninvasive glucose monitoring device, purchase
S1031 — Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor
S1034 — Artificial Pancreas Device System (including CGM, blood glucose device, insulin pump, and computer algorithm)
S1035 — Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system
S1036 — Transmitter; external, for use with artificial pancreas device system
S1037 — Receiver (monitor), external, for use with artificial pancreas device system
S8130 — Interferential current stimulator, 2 channel
S8131 — Interferential current stimulator, 4 channel
S9001 — Home uterine monitor with or without associated nursing services

Key Terms & Unit Definitions

HCAP — Home Care Advocacy Program

HCAPHome Care Advocacy Program — program to which listed DME items must be notified prior to delivery for members with The Empire Plan as primary coverage.

Notification consequenceFailure to notify HCAP prior to delivery will result in no payment for the item, except in emergencies.

Effective datePolicy effective January 1, 2025 (updated 10/13/25).

Unit of service definitions

CGM monthly supply unit1 month supply = 1 unit of service for CGM supplies (A4238, A4239).

Insulin pump suppliesA4226 listed with weekly supply description (supplies for maintenance of insulin infusion pump, per week).

General noteUnit definitions apply to the specific HCPCS codes as described in the DME listing; confirm code-level unit when submitting notification and claim.

Power mobility device not coded by DME PDAC / does not meet criteria (K0899)

Definition (K0899)K0899 = Power mobility device, not coded by DME PDAC or does not meet criteria.

ImplicationK0899 is used when a power mobility device lacks a PDAC code or does not satisfy established code criteria; such items remain subject to notification requirements.

Related codesK0898 (not otherwise classified) and other K-codes in the power wheelchair groups appear nearby in the DME listing.

Artificial Pancreas Device System (S1034)

Definition (S1034)S1034 = Artificial Pancreas Device System, including Continuous Glucose Monitor, Blood Glucose Device, Insulin Pump, and Computer Algorithm that communicates with all of the Devices.

Associated S-codesS1035: sensor (disposable) for artificial pancreas; S1036: transmitter; S1037: receiver (monitor).

Related CGM codesA4238/A4239 and S1030/S1031 are other continuous glucose monitoring device codes referenced in the DME list.