Provider Manual Section 5.0

Transcription

1 Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria/Standards for Review 5.3 Authorization Requirements 5.4 Online Authorization 5.5 Inpatient Admissions and Observation 5.6 Outpatient Services 5.7 High Cost Medication 5.8 Prior Authorization for Members with Original Medicare 5.9 Retrospective Authorization 5.10 Denials Page 1 of 39

2 5.0 Utilization Management 5.1 Utilization Management Utilization Management (UM) is the process of influencing the continuum of care by evaluating the necessity and efficiency of health care services and affecting patient care decisions through assessments of the appropriateness of care. The UM department helps to assure prompt delivery of medicallyappropriate health care services to Passport Health Plan members and subsequently monitors the quality of care. Medically Necessary or Medical Necessity means Covered Services which are medically necessary as defined under 907 KAR 3:130 or other applicable Kentucky law or regulation, and provided in accordance with 42 CFR , including children s services pursuant to 42 U.S.C. 1396d(r). All Passport Health Plan participating providers are required to obtain prior authorization from the Plan s UM department for inpatient services and specified outpatient services listed in Section 5.3, Authorization Requirements. Failure to submit an authorization or failure to submit an authorization in a timely manner may result in a denial of services. An authorization is not a guarantee of benefits. Member eligibility should be verified for every request of service. The UM department is available Monday through Friday from 8:00 a.m. to 5:30 p.m. EST, except holidays. All requests for authorization of services may be received during these hours of operation by calling or faxing: Department Phone Number Fax Number General Number (800) (502) Concurrent Review (502) (502) Retrospective Review (502) (502) Home Health (502) (502) DME (502) (502) Therapies/Pain Management (502) (502) Cosmetics (502) Request can be sent via confidential to: Appeals (502) (502) High Dollar Radiology Administered by MedSolutions or on-line authorization at After business hours or on holidays, a provider can leave a message and a representative will return the call the next business day. Passport Health Plan provides the opportunity for the provider to discuss a decision with the Medical Page 2 of 39

3 Director, to ask questions about a utilization management issue, or to seek information from the nurse reviewer about the Utilization Management process and the authorization of care by calling Utilization Management at (800) Because of frequent changes in member eligibility for Medicaid coverage, providers should verify continued eligibility via the Plan s web site, or by calling the IVR or Provider Services at (800) Review Criteria/Standards for Review Passport Health Plan s Utilization Management (UM) department is charged with ensuring that the Plan s members use their benefits appropriately. Passport s UM Department uses InterQual Criteria during the review process. In the event InterQual Criteria is not available for a specific request, the reviewer may use internal medical policies which are reviewed and approved by actively practicing practitioners in the community. The Partnership Council approves both the use of InterQual Criteria and Medical Polices. Criteria are only made available to participating and non-participating providers as allowed under copyright limitations and trademark considerations. At the request of the practitioner, the Passport UM Department, or the Chief Medical Officer, will provide a copy of up to three (3) InterQual Criteria guidelines. If the guidelines are not available for distribution, or the number of guidelines exceeds the copyright limit, the practitioner has the option to request the guideline be read over the telephone, or review the guideline at Passport Health Plan. Internal Medical policies are communicated to providers via the Provider Newsletter or the Passport Health Plan web site, Providers may request a copy of a policy at any time from the Passport UM Department or the Chief Medical Officer. Durable medical equipment is reviewed utilizing Medicaid and Medicare guidelines as well as any applicable Passport Health Plan internal medical policies. Medicare and Medicaid criteria/guidelines are shared with providers upon request. These requests may be made by contacting the UM Department or the Chief Medical Officer. Criteria are distributed to providers who have Medicare/Medicaid practitioner numbers issued by state and federal entities. 5.3 Authorization Requirements The Passport UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. The general UM department phone number is: (800) The general UM department fax number is (502) The following table lists procedures and/or services that require authorization from Passport Health Plan s Utilization Management (UM) department. Services Requiring Authorization Page 3 of 39

4 All Inpatient Admissions / Hospitalizations Maternity Code Range: 644.XX through 665.XX --- If stay is less than or equal to 3 days with the above codes, no authorization is required AUTHORIZATION IS REQUIRED FOR: All Cesarean Sections All Scheduled inductions All Non-par providers, regardless of delivery type Rehabilitation Pain Management (i.e. Epidural Blocks Trigger Point Injections) Stem Cell/Progenitor Cell Retrieval Cosmetic Procedures Neuropsychological Testing Therapy Services 23 Hour Observation greater than one (1) overnight stay Home Hospice Investigational/Experimental Procedures Ocular Photodynamic Therapy/with Verteporfin (Visudyne) Diabetic Education Chiropractic Services No authorization for the first 12 visits in a calendar year Services beyond 12 visits require authorization Benefit limit = total of 26 chiropractic visits within a calendar period Specified Outpatient Surgical Procedures: PET Scan / MRI / MRA / CT / CTA / Select Cardiac Imaging Authorization administered by MSI Adenoidectomy - Cardiac Catheterization - EGD DME > $500 rental or purchase Enteral Products Ostomy Supplies Home Infusion IV Therapy (IVT) All DME with E1399 Codes Select Orthotics / Prosthetics Home Health / Skilled Nursing / Private Duty Nursing High Cost Medication > $400 Authorization for IVT will be administered by PBM Synagis Injections Synagis Injections Authorizations administered by PBM Nonparticipating Provider Services Page 4 of 39

5 Select EPSDT Special Services Family Planning Terminations To determine if a service or supply, such as cosmetic procedures, is considered benefit exclusion, please contact the Passport Utilization Management (UM) department. The assigned authorization number must be submitted on the claim form. Policy for Newborns: An infant born by Normal Vaginal Delivery (NVD) does not require authorization until day four (4). If an infant born via NVD stays <= 3 days, authorization is not required. An infant born by C-Section does not require authorization until day six (6). If an infant born via C- Section stays <= 5 days, authorization is not required. Benefit inclusions/exclusions must be considered in determining eligibility for coverage for individual cases. To determine if a service or supply, such as cosmetic procedures, is considered a benefit exclusion, please contact the Passport Utilization Management (UM) department. The assigned authorization number must be submitted on the claim form. 5.4 Online Authorization Passport Health Plan s Utilization Management Department utilizes an online authorization system via NaviNet. The online authorization system is a web-based auto-review system for providers to obtain authorization for services. For questions regarding the online authorization, contact NaviNet or your Provider Network Account Manager. The online authorization system also allows you, the provider, to search for authorizations by member, authorization number, date of service and/or physician. View the following information online for each authorization: Member identification number, coverage dates, and PCP Authorization number Service requested Primary diagnosis Treatment dates Status of the authorization The use of the online authorization system via NaviNet for select services is highly encouraged. Page 5 of 39

6 5.5 Inpatient Admissions UM reviews all requests for inpatient admissions utilizing InterQual criteria and internal medical policies. For those requests meeting the established medical necessity criteria, an inpatient will be authorized. Requests not meeting the established medical necessity criteria will be referred to Passport s Medical Director for further review and evaluation. When requesting a review, at a minimum, documentation must include: The member s name and Passport Health Plan ID number. The diagnosis for which the treatment or testing procedure is being sought. Other treatment or testing methods that have been tried, their duration, and any outcomes. Additional clinical information as applicable to the requested service. Applicable sections of the medical record. Some authorization requests may require a physician s letter of medical necessity or a copy of the medical records. These should be directed to the Utilization Management nurse who is coordinating the specific case. To receive authorization for an admission, contact Passport Health Plan s Utilization Management department at (800) or fax request to (502) , Monday through Friday, between the hours of 8 a.m. and 5:30 p.m Inpatient Admissions and Observation Requirements All inpatient admissions require an authorization. If a member is discharged from an inpatient level of care and subsequently re-admitted to the same hospital within 24 hours, the UM Department continues the member's inpatient stay under the same case reference number. Requests for prior authorization of elective inpatient services should be received prior to the date the requested service will be performed. Passport Health Plan will accept the hospital s or the attending physician s request for prior authorization of elective hospital admissions; however, neither party should assume that the other has obtained prior authorization. For an urgent or emergent admission, the facility must notify the plan within one business day of the admission. For weekend admissions to a hospital or for services delivered on the weekend or after normal business hours, authorization must be obtained within one business day of the admission or service being provided. If the member s condition or results of evaluation and testing meet inpatient criteria after the 23-hour observation period, the stay will be converted to inpatient beginning with the observation stay admission date. All claims for this type of stay should be submitted with the entire length of stay as an Page 6 of 39

7 inpatient. To receive authorization for an inpatient admission, contact Passport Health Plan s Utilization Management department at (800) or fax the request to (502) , Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST. To receive authorization for an inpatient admission, contact Passport Health Plan s Utilization Management department at (800) or fax request to (502) , Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST. Failure to obtain authorization of an admission will result in an administrative denial of the admission (see Section 2.11). Denied authorization requests may be appealed (see Section 2.11). Inpatient Only Codes: In accordance with the Centers for Medicare and Medicaid Services (CMS) billing requirements, select surgical procedures must be performed in the inpatient setting. A detailed list of codes may be obtained at the following CMS website: Payment/HospitalOutpatientPPS/downloads/cms-1427-p_addE.pdf If a provider performs one of the listed procedures in an outpatient setting and the claim is denied, they may submit supporting medical records documentation for review through the claims appeals process Inpatient Admissions to Non-Participating Facilities Requests for admission to non-participating facilities should be submitted to the Passport Health Plan UM department for review. To receive authorization for admission to a non-participating facility, contact Passport Health Plan s Utilization Management department at (800) or fax the request to (502) , Monday through Friday, between the hours of 8 a.m. and 5:30 p.m. EST Elective Participating-Hospital Transfer Policy Elective participating facility transfers must be prior authorized by Passport Health Plan. Patient clinical information will be required to complete the authorization process, approve the transfer, and determine prospective length of stay. Either the transferring or receiving facility may initiate the prior authorization; however, the transferring facility will be able to provide the most accurate required clinical information. If a hospital transfer request is made by another Passport Health Plan facility, the receiving facility may request that the transferring facility obtain the authorization before the case will be accepted at the receiving facility. Page 7 of 39

8 The receiving facility should contact Passport Health Plan to confirm the authorization. In cases deemed emergent, notification of the admission is required within one business day after the transfer. To assist with transfers, contact Passport Health Plan s Utilization Management department at (800) or fax the request to (502) , Monday through Friday, between the hours of 8 a.m. and 5:30 p.m Inpatient Rehabilitation Admissions If a member requires an inpatient rehabilitation admission, the rehabilitation hospital will contact the on-site review nurse at the acute-care facility where the member is currently an inpatient. If there is not an on-site review nurse at the acute-care facility, the rehab hospital can contact Passport Health Plan s Utilization Management via phone (800) or fax (502) Inpatient rehabilitation includes Acute Inpatient Rehab, Inpatient Cardiac Rehab and Inpatient Pulmonary Rehab. If the member is to be directly admitted from home or any other sub-acute facility, contact Passport Health Plan s Case Management department at (800) ext Inpatient Skilled-Nursing Facility Passport Health Plan is not responsible for, nor does it reimburse nursing facility costs, for members at skilled-nursing facilities. Those services are covered by the Kentucky Medicaid Program. Passport Health Plan is responsible for costs of professional services, such as physician or therapist services that are not part of the routine facility service. After a member is in a nursing facility for 31 days, the disenrollment process begins for that member. Passport Health Plan s responsibility for those nonfacility services continues for any of its members while they are still enrolled with the Plan. After the Kentucky Medicaid Program completes the managed care disenrollment process and reinstates the member in the fee-for-service Medicaid program, the Plan no longer has financial responsibility for any services for that Medicaid recipient. To obtain skilled-nursing facility authorization, please call the DMS-contracted review entity. 5.6 Outpatient Services For authorization of select outpatient services listed in Section 5.3, Authorization Requirements, the PCP/specialist notifies Passport Health Plan via the online authorization system, telephonically or by fax. Prior authorization is mandatory for select outpatient procedures / diagnostics to qualify for payment. When requesting a review, at a minimum, documentation submitted must include: The member s name and Passport Health Plan ID number. The diagnosis for which the treatment or testing procedure is being sought. Other treatment or testing methods that have been tried, their duration, and any outcomes. Page 8 of 39

9 Additional clinical information as applicable to the requested service. Applicable sections of the medical record. Some authorization requests may require a physician s letter of medical necessity or a copy of the medical records. These should be directed to the Utilization Management nurse who is coordinating the specific case. Requests for prior authorization of elective services should be received prior to the date the requested service will be performed. Requests for authorization of urgent and emergent services must be submitted to UM within one business day of the procedure being performed. Passport Health Plan will accept the hospital s or the attending physician s request for prior authorization of elective hospital admissions; however, neither party should assume that the other has obtained prior authorization. Failure to obtain prior authorization for an elective procedure / service or failure to request authorization of an urgent or emergent procedure / service within one business day of the procedure/ service being performed or rendered will result in an administrative denial of the service (see Section ). Denied requests may be appealed (see Section 2.11). The assigned prior-authorization number must be on the claim form. If practitioners wish to confirm authorization, they may verify online via the online authorization system Outpatient Procedures / Diagnostics / Services Providers are required to obtain prior authorization for select outpatient procedures / diagnostics from the Plan s Utilization Management Department. See Table in section 5.3 for outpatient list. For authorization of select outpatient services listed in Section 5.3, Authorization Requirements, the provider notifies Passport Health Plan via the online authorization system, telephonically or by fax. The general UM department phone number is: (800) The general UM department fax number is (502) For Outpatient Imaging Services requiring authorization, see section Outpatient Radiology Services Providers are required to obtain authorization for select radiological services through the high dollar radiology program for advanced diagnostic imaging services. This program is administered in partnership with MedSolutions (MSI). Authorizations are required for select diagnostic imaging services performed in an outpatient setting. Advanced diagnostic imaging includes: Page 9 of 39

10 Computed Tomography (CT); Computed Tomographic Angiogram (CTA) Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA) Positron Emissions Tomography (PET) Nuclear Cardiac Imaging (NCM) Authorizations are performed at MSI using their own internal criteria and medical management system. MSI performs initial review, retrospective review, denials and 1st level appeals. Authorization is required for advanced diagnostic imaging services performed in any outpatient setting. Authorization is NOT required if the imaging service is performed in: Emergency rooms Inpatient settings 23-hour observations Service performed in observation do not require an authorization. There are three (3) ways to request an authorization: 1. Internet: - Available 24/7 2. Phone: (877) Available 8 a.m. - 9 p.m. EST, Monday through Friday Toll free 3. Fax: Forms available at or by calling MedSolutions Customer Service at (877) Only MedSolutions fax forms are accepted Available 24/7 See Appendix A for a list of codes that require an authorization Durable Medical Equipment The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the supplier for a period of five (5) years. The only exception is oxygen for which Passport Health Plan follows Medicare guidelines. DME PURCHASE DME items with billable charges greater than $500 require an authorization. Requests for authorization of purchase MUST be received PRIOR to the end of the rental period. DME RENTAL Authorization requirements of rentals are determined by the billable price of the item being rented. Rental charges will be applied to purchase price. If the billable price of the rental is $500 or less, no authorization is required. If the billable price of the rental is greater than $500, authorization is required. All items requiring customization or accessories require prior authorization. Page 10 of 39

11 All mini-nebulizers will be a purchase only item and do not require prior authorization. Authorization requirements for DME purchases are based on total monthly cost or monthly quantity of items purchased. The following is a list of purchases with authorization requirements by quantity: Name Brand Diapers Generic Diapers Underpads (Chux) Ostomy Supplies Bedside Drainage Bags Syringes G-Tube Compression Stockings Item m Quantity Limitations Regardless of quantity, all requests for name brand diapers require authorization 180 per month require authorization 180 per month require authorization 2 boxes per month require authorization 4 per month require authorization 100 per month require authorization 1 per month requires authorization 6 pair per year require authorization * Maintenance, repair, or replacement in excess of $500 must have prior authorization from the UM department.* Enteral Products Enteral products with allowable amounts greater than $500 for a month s supply require an authorization. These services should be billed according to the fee schedule in your Provider Contract (Allowable Charges). For authorization of DME, the provider notifies Passport Health Plan via the online authorization system, telephonically or by fax. The DME phone number is: (502) The DME fax number is: (502) For a list of Orthotics and Prosthetics that require an Authorization, see Appendix A. For a list of Ostomy supplies that require an Authorization, see Appendix B Home Health Services When medically appropriate, home health, private duty nursing, or home infusion may be a good alternative to hospitalization. Prior authorization of all home health / private duty nursing / hospice / home infusion services is required. If the member is an inpatient and the facility has a Passport Health Plan on-site nurse reviewer, the request may be given directly to the on-site review nurse. Private duty nursing is limited to 2,000 hours per calendar year. Additional hours for children may be obtained under EPSDT Special Services. A request for prior authorization must be received prior to the delivery of the service for a non-urgent request and within one business day of the service being performed for an urgent or emergent service. Page 11 of 39

12 For authorization of Home Health Services, including home health care, private duty nursing and home hospice, the provider notifies Passport Health Plan through the online authorization system, telephonically or by fax. The Home Health phone number is: (502) The Home Health fax number is: (502) For authorization of home infusion, the provider should submit the infusion therapy authorization form to Magellan via fax at (800) The authorization form can be found at Therapy, Chiropractic Services and Outpatient Rehab Services Providers are required to obtain prior authorization for physical, occupational, aquatic and speech therapy for acute and chronic conditions and chiropractic services. Therapy Authorization of outpatient therapy services (physical, occupational, aquatic and speech) is required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the request may be given directly to the onsite review nurse. Review is required for the initial therapy visit and all subsequent visits. Requests for continuation of a service that is ongoing should be sent to the therapy department seven days prior to the end of the authorization period. Please fax request together with progress notes and current plan of care to (502) For authorization of therapy requests, providers must notify Passport Health Plan through the online authorization system, telephonically or by fax. The therapy phone number is: (502) The therapy fax number is (502) Chiropractic Services Authorization requests for chiropractic services are required after the 12 th visit. No authorization is required for the first 12 visits in a calendar year. The benefit limit equals the total of 26 chiropractic visits within a 12-month calendar period. Outpatient Rehab Services Authorization requests for outpatient rehab services (cardiac rehab and pulmonary rehab) are required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the request may be given directly to the onsite review nurse. For authorization of chiropractic or outpatient rehab services, providers must notify Passport Health Plan telephonically at (502) or via fax at (502) High-Cost Medications Providers are required to obtain prior authorization for High-Cost Medications greater than $400 billable amount per dose from the Utilization Management Department. This applies to high-cost medications billed to Passport Health Plan, excluding chemotherapy. This Page 12 of 39

13 does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy. Authorizations for Synagis must be requested from Passport s Pharmacy Benefits Manager. See section 14 for prior authorizations related to pharmacy. For requests of high cost medications, providers may contact the UM Department at (800) or fax the request to (502) Prior Authorization for Members with Medicare Prior authorization is not required for services listed on the prior authorization list when the member has Medicare as the primary payer and benefits under Medicare have not been exhausted. This applies to both inpatient and outpatient services. When benefits are exhausted, or if the service is not a benefit covered under Medicare, and Passport Health Plan becomes the primary payer, prior authorization requirements apply for both outpatient and inpatient services. For those members who have exhausted their Medicare Part A inpatient lifetime reserve days, prior authorization of inpatient services must be obtained. If a member s lifetime reserve days are exhausted during an inpatient hospitalization, notification to Passport Health Plan must be made within one business day of the notification to the facility of the exhaustion of benefits by Medicare. 5.9 Retrospective Authorization Retrospective review of inpatient services is performed when the patient was not a member of Passport Health Plan prior to or at the time of the service. Outpatient services do not require retrospective review by Utilization Management for members whose eligibility is determined retrospectively. Providers have 60 days from the notification of eligibility on retrospectively enrolled members to submit medical records for review and utilization management authorization request. If the practitioner does not provide documentation, the card issue date, segment date, and claims history are used. A decision and written notification is provided within ten (10) business days of receipt of the medical information for the retrospective review request. An administrative denial is issued for retrospective requests when the provider fails to request a utilization management review of the medical record within the timeframe specified. The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written notification is provided. Requests received beyond 60 days from the card issue date or from the provider s documentation of the date when they were aware of the member s eligibility will be administratively denied. Send requests for retrospective review to: Utilization Management Retrospective Review 5100 Commerce Crossings Drive Louisville, KY Page 13 of 39

14 The phone number for retrospective review is: (502) or fax to: (502) (for large chart review, please send records via mail) Denials An authorization request for a service may be denied for failure to meet guidelines, protocols, medical policies, or failure to follow administrative procedures outlined in the Provider Contract or this Provider Manual. Members may not be billed by participating providers for deductibles, copays, and coinsurance except those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim, members must be held harmless for denied services. To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact Utilization Management at (800) Medical Necessity Denials Utilization Management utilizes InterQual Guidelines, medical policies and protocols to render review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a Medical Director for clinical review. A Passport Health Plan Medical Director renders all medical necessity denial decisions. Whenever a denial is issued, Utilization Management provides the name, telephone number, title, and office hours of the Medical Director who rendered the decision. The Passport Health Plan Medical Director is available to discuss any decision rendered with the attending practitioner Administrative Denials An administrative denial is issued for those services for which the provider has not followed the requirements set forth in the Provider Contract or this Provider Manual. For example, an administrative denial may be issued for failure to prior authorize an elective service, procedure, or admission. It may also be issued for failure to notify Utilization Management within one business day of an emergency service, procedure, or admission. A provider may appeal an administrative denial by submitting the appeal request in writing to: Clinical Appeals Department 5100 Commerce Crossings Drive Louisville, KY Appendix A: Radiology Codes The codes on the list below require authorization through MedSolutions CPT CPT Code CPT Description MRI TMJ Category MRI Temporomandibular Joint (s) CT CT Head without contrast Page 14 of 39

15 CPT CPT Code CPT Description CT Category CT Head with contrast CT CT Head with & without contrast CT CT Orbit, et al without contrast CT CT Orbit, et al with contrast CT CT Orbit, et al W & W/O CT CT Maxillofacial area, (sinus) without contrast CT CT Maxillofacial area, (sinus) with contrast CT CT Maxillofacial area, (sinus) W & W/O CT CT Soft-tissue Neck without contrast CT CT Soft-tissue Neck with contrast CT CT Soft-tissue Neck with & without contrast W & W/O CT Angiography (CTA) CTA HEAD, with contrast, including noncontrast images, if performed, & image post-processing CT Angiography (CTA) CTA NECK, with contrast, including noncontrast images, if performed, & image post-processing MRI MRI Orbit, Face and/or Neck without contrast MRI MRI Orbit, Face and/or Neck with contrast MRI MRI Orbit, Face and/or Neck W & W/O MRA MR Angiography (MRA) Head without contrast MRA MR Angiography (MRA) Head with contrast MRA MR Angiography (MRA) Head with and without contrast W & W/O MRA MR Angiography (MRA) Neck without contrast MRA MR Angiography (MRA) Neck with contrast MRA MR Angiography (MRA) Neck with and without contrast W & W/O MRI MRI Brain (Head) without contrast MRI MRI Brain (Head) with contrast MRI MRI Brain (Head) with and without contrast W & W/O Functional MRI (fmri) MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration Functional MRI (fmri) MRI, Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing CT CT Chest without contrast CT CT Chest with contrast CT CT Chest with and without contrast W & W/O CT Angiography (CTA) CTA CHEST, (non-coronary), with contrast, including noncontrast images, if performed, & image post-processing MRI MRI Chest without contrast MRI MRI Chest with contrast MRI MRI Chest with and without contrast W & W/O MRA MR Angiography (MRA) Chest (excluding myocardium)- W or W/O CT CT Cervical Spine without contrast CT CT Cervical Spine with contrast Page 15 of 39

16 CPT CPT Code CPT Description CT Category CT Cervical Spine with and without contrast W & W/O CT CT Thoracic Spine without contrast CT CT Thoracic Spine with contrast CT CT Thoracic Spine with and without contrast W & W/O CT CT Lumbar Spine without contrast CT CT Lumbar Spine with contrast CT CT Lumbar Spine with and without out contrast W & W/O MRI MRI Cervical Spine without contrast MRI MRI Cervical Spine with contrast MRI MRI Thoracic Spine without contrast MRI MRI Thoracic Spine with contrast MRI MRI Lumbar Spine without contrast MRI MRI Lumbar Spine with contrast MRI MRI Cervical Spine with and without contrast W & W/O MRI MRI Thoracic Spine with and without contrast W & W/O MRI MRI Lumbar Spine with and without contrast W & W/O MRA MR Angiography (MRA) Spinal Canal and contents -with or w/o contrast CT Angiography (CTA) CTA PELVIS, with contrast, including noncontrast images, if performed, & image post-processing CT CT Pelvis without contrast CT CT Pelvis with contrast CT CT Pelvis with and without contrast W & W/O MRI MRI Pelvis without contrast MRI MRI Pelvis with contrast MRI MRI Pelvis with and without contrast W & W/O MRA MR Angiography (MRA) Pelvis -with or without contrast CT CT Upper Extremity without contrast CT CT Upper Extremity with contrast CT CT Upper Extremity with and without contrast W & W/O CT Angiography (CTA) CTA Upper Extremity, with contrast, including noncontrast images, if performed, & image postprocessing MRI MRI Upper Extremity-other than joint-without contrast MRI MRI Upper Extremity-other than joint-with contrast MRI MRI Upper Extremity-other than joint-w & W/O MRI MRI Any Joint of Upper Extremity--without contrast MRI MRI Any Joint of Upper Extremity--with contrast MRI MRI Any Joint of Upper Extremity W & W/O MRA MR Angiography (MRA) Upper Extremity -with or without contrast CT CT Lower Extremity without contrast CT CT Lower Extremity with contrast CT CT Lower Extremity with and without contrast W & W/O CT Angiography (CTA) CTA Lower Extremity, with contrast, including noncontrast images, if performed, & image postprocessing MRI MRI Lower Extremity-other than joint-without contrast MRI MRI Lower Extremity-other than joint-with contrast Page 16 of 39

17 CPT CPT Code CPT Description MRI Category MRI Lower Extremity-other than joint- W & W/O MRI MRI Any Joint of Lower Extremity--without contrast MRI MRI Any Joint of Lower Extremity--with contrast MRI MRI Any Joint of Lower Extremity W & W/O MRA MR Angiography (MRA) Lower Extremity-with or without contrast CT CT Abdomen without contrast CT CT Abdomen with contrast CT CT Abdomen with and without contrast W & W/O CT Angiography (CTA) Computed tomographic angiography; abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing CT Angiography (CTA) CTA ABDOMEN, with contrast, including noncontrast images, if performed, & image postprocessing CT CT Abdomen & Pelvis, without contrast CT CT Abdomen & Pelvis, with contrast CT CT Abdomen & Pelvis, with and without contrast MRI MRI Abdomen without contrast MRI MRI Abdomen with contrast MRI MRI Abdomen with and without contrast W & W/O MRA MR Angiography (MRA) Abdomen-with or without contrast Diagnostic CT Colonography (CTC) Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material Diagnostic CT Colonography (CTC) Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including noncontrast images, if performed Computed tomographic (CT) colonography, screening, including image postprocessing CT Colonography (CTC) for Screening Cardiac MRI Cardiac MRI for morphology and function without contrast Cardiac MRI Cardiac MRI for morphology and function without contrast material; with stress imaging Cardiac MRI Cardiac MRI for morphology and function without contrast, followed by contrast W & W/O Cardiac MRI Cardiac MRI for morphology and function without contrast, followed by contrast; with stress imaging Cardiac MRI Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Cardiac CT Calcium CT, heart, without contrast with quantitative Scoring Cardiac CT CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed) Page 17 of 39

18 CPT CPT Code CPT Description Cardiac CT Category CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of cardiac LV function, RV structure and function and evaluation of venous structures, if performed) CT Coronary Angiography (CTCA) CT, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) CT Angiography (CTA) CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast, including noncontrast images, if performed, and image post-processing 3D Rendering D Rendering with interpretation and reporting of CT, 3D Rendering D Rendering with interpretation and reporting of CT, CT CT Limited or Localized follow-up MR Spectroscopy (MRS) MR Spectroscopy (MRS) Unlisted CT Unlisted CT procedure (eg, diagnostic, interventional) Unlisted MR Unlisted MR procedure (eg, diagnostic, interventional) CT guidance CT guidance stereotactic localization CT guidance CT guidance needle placement (eg, biopsy, aspiration, injection, localization device) CT guidance CT Guidance for, and monitoring of, parenchymal tissue MR Guidance MR guidance for needle placement (eg, for biopsy, MR Guidance MR guidance for, and monitoring of, parenchymal tissue Breast MRI MRI BREAST, without and/or with contrast UNILATERAL Breast MRI MRI BREAST, without and/or with contrast BILATERAL CT Bone Density CT BONE MINERAL DENSITY study, 1 or more sites, axial MRI Bone Marrow skeleton MRI Bone Marrow blood supply Nuclear Cardiac Imaging Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Nuclear Cardiac Imaging Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Nuclear Cardiac Imaging Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Page 18 of 39

19 CPT CPT Code CPT Description Nuclear Category Cardiac Imaging Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Cardiac PET PET Cardiac (myocardial imaging) metabolic evaluation Nuclear Cardiac Imaging Myocardial Imaging, infarct avid, planar; qualitative or quantitative Nuclear Cardiac Imaging Myocardial Imaging, infarct avid, planar; w/ EF by first pass technique Nuclear Cardiac Imaging Myocardial Imaging, infarct avid, planar; tomographic SPECT Nuclear Cardiac Imaging Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress Nuclear Cardiac Imaging Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress Nuclear Cardiac Imaging Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction Nuclear Cardiac Imaging Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction Cardiac PET PET Cardiac (myocardial imaging), perfusion single study at rest or stress Cardiac PET PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress Nuclear Cardiac Imaging Cardiac Blood Pool imaging, gated equilibrium, SPECT Nuclear Cardiac Imaging Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass Unlisted Nuclear Unlisted Nuclear Cardiology diagnostic nuclear Cardiology Non-Cardiac PET PET Brain metabolic evaluation Non-Cardiac PET PET Brain perfusion evaluation Non-Cardiac PET PET imaging; limited area (eg, chest, head/neck) Non-Cardiac PET PET imaging; skull base to mid-thigh Non-Cardiac PET PET imaging; whole body Non-Cardiac PET PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; limited area (eg, chest, head/neck) Non-Cardiac PET PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh Non-Cardiac PET PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; whole body Ceberal Perfusion 0042T Ceberal Perfusion Analysis using CT with contrast Analysis CAD for Breast MRI 0159T CAD, including computer algorithm analysis, BREAST Magnetic Source Imaging S8035 Magnetic Source Imaging Page 19 of 39

20 CPT CPT Code CPT Description MRCP Category S8037 MRCP (Magnetic ResonancE) MRI Low field S8042 MRI Low field Cardiac CT Calcium Scoring S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring Page 20 of 39

21 Appendix B Orthotics and Prosthetics (L codes) AUTHORIZATION REQUIRED HCPCS Description HCPC Description L0113 Cranial cervical orthosis, torticollis type, S L5460 Postop app non-wgt bear dsg w/wo joint, w/o soft interface, prefab. Incl. fitting & adj. L0130 Flex thermoplastic collar molded to L5500 Init bk ptb plaster direct patient L0170 Cervical collar molded to pt L5505 Init ak ischal plstr direct L0220 Thor rib belt custom fabrica L5510 Prep BK ptb plaster molded L0430 Spinal orthosis, Dewall posture protector L5520 Perp BK ptb thermopls direct L0452 TLSO flexible, provides trunk support, L5530 Prep BK ptb thermopls molded upper thoracic region, customized L0456 TLSO, flexible thoracic region, prefab L5535 Prep BK ptb open end socket L0460 TLSO, triplanar control prefab L5540 Prep BK ptb laminated socket L0462 TLSO, triplanar control, prefab L5560 Prep AK ischial plast molded L0464 TLSO, triplanar control 4 piece rigid L5570 Prep AK ischial direct form plastic with interface, prefab L0480 TLSO, triplanar control, one piece rigid L5580 Prep AK ischial thermo mold plastic shell L0482 TLSO, triplanor, custom fabricated, one L5585 Prep AK ischial open end piece rigid plastic shell, each L0484 TLSO, triplanor control, two piece L5590 Prep AK ischial laminated L0486 TLSO, triplanor control 2 piece rigid L5595 Hip disartic sach thermopls plastic with interface, custom L0488 TLSO triplanor, one piece, prefab L5600 Hip disart sach laminat mold L0491 TLSO 2 rigid plastic shells, pre fab L5610 Above knee hydracadence L0622 Sacroiliac orthosis, flexible, custom L5611 Ak 4 bar link w/fric swing L0623 Sacroiliac orthosis, rigid or semi-rigid, L5613 Ak 4 bar ling w/hydraul swig pre fab L0624 Sacroiliac orthosis, rigid or semi-rigid, L bar link above knee w/swng custom L0629 Lumbar-sacral orthosis, flexible, custom L5616 Ak univ multiplex sys frict L0631 Lumbar-sacral orthosis, sagittal control, L5639 Below knee wood socket pre fab L0632 Lumbar-sacral orthosis, sag. Control, L5643 Hip flex inner socket ext fr rigid ant./post. Custom L0634 Lumbar-sacral orthosis, sag. Control, rigid post., custom L5645 Ak flexibl inner socket ext Page 21 of 39

22 L0635 L0636 L0637 L0638 L0639 L0640 Lumbar-sacral orthosis, sag-coronal control, prefab Lumbar-sacral orthosis, sag-coronal control, custom Lumbar-sacral orthosis, sag-coronal control, rigid ant/post., prefab Lumbar-sacral orth, sag-coronal control, rigid ant./post., custom Lumbar-sacral orthosis, sag.-coronal control, rigid post. Prefab Lumbar-sacral orthosis, sag-coronal control, rigid post., custom L5647 L5648 L5649 L5651 L5670 L5673 Below knee suction socket Above knee air cushion socket Isch containmt/narrow m-l so Ak flex inner socket ext fra Bk molded supracondylar susp below knee/above knee socket insert, silicone gel or elastomeric w/locking mech, custom L0700 Ctlso a-p-l control molded L5679 below knee/above knee socket insert, silicone gel or elastomeric no locking mech, custom L0710 Ctlso a-p-l control w/ inter L5681 below knee/above knee, custom fab. Socket inset initial only for cong. Or atypical L0810 Halo cervical into jckt vest L5682 Bk thigh lacer glut/ischia molded L0820 Halo cervical into body jack L5683 below knee/above knee, custom fab, socket inset, initial only not cong.or atypical L0830 Halo cerv into milwaukee typ L5700 Replace socket below knee L0999 Addition to spinal orthosis, NOS L5701 Replace socket above knee L1000 Ctlso milwauke initial model L5702 Replace socket hip L1001 Cervical TLSO, infant, prefab L5704 Custom shape covr below knee L1200 Furnsh initial orthosis only L5705 Custom shape cover above knee L1300 Body jacket mold to patient L5706 Custom shape cvr knee disart L1310 Post-operative body jacket L5707 Custom shape cover hip disart L1499 Spinal orthosis NOS L5716 Knee-shin exo mech stance ph L1500 Thkao mobility frame L5718 Knee-shin exo frct swg & sta L1510 Thkao standing frame L5722 Knee-shin pneum swg frct exo L1520 Thkao swivel walker L5724 Knee-shin exo fluid swing ph L1680 Pelvic & hip control thigh c L5726 Knee-shin ext jnts fld swg e L1685 Post-op hip abduct custom fa L5728 Knee-shin fluid swg & stance L1686 HO post-op hip abduction L5780 Knee-shin pneum/hydra pneum L1690 Combination bilateral LS/hip/femur L5781 Addt. to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system L1700 Legg perthes orth toronto typ L5782 Addt. To lower leg prosth. Vacuum L1710 Legg perthes orth newington L5790 Exoskeletal ak ultra-light m L1720 Legg perthes orthosis trilat L5795 Exoskel hip ultra-light mate Page 22 of 39

23 L1730 Legg perthes orth scottish L5811 Endo knee-shin mnl lck ultra L1755 Legg perthes patten bottom L5814 Endo knee-shin hydral swg ph L1832 KO adj jnt pos rigid support L5816 Endo knee-shin polyc mch sta L1834 KO w/0 joint rigid molded to L5818 Endo knee-shin frct swg & st L1840 KO derot ant cruciate custom L5822 Endo knee-shin pneum swg frc L1843 KO single upright thigh & calf- L5824 Endo knee-shin fluid swing p prefabricated, each L1844 KO w/adj jt rot cntrl molded L5826 Miniature knee joint L1845 KO w/ adj flex/ext rotat cus L5828 Endo knee-shin fluid swg/sta L1846 KO w adj flex/ext rotat mold L5830 Endo knee-shin pneum/swg pha L1860 KO supracondylar socket mold L5840 Multi-axial knee/shin system L1904 AFO molded ankle gauntlet L5845 Knee-shin sys stance flexion L1907 supramalleolar w/straps w/wo interface/pads, custom fabricated L5848 Knee-shin system dampening feature L1932 AFO, rigid anterior tibial section,pre fab, incl. Fitting & adj. L5856 Addt. To lower ext. prosthesis, knee shin sys.,microprocessor, incl. Sensor, any type L1940 AFO, plastic or other material custom L5857 Addt. To lower ext. prosth., swing phase only knee shin sys.,micro, incl. Sensor, any type L1945 AFO molded plas rig ant tib L5858 Addt. To lower ext. prosth, knee shin sys.,micro, incl. Sens, stance phase L1950 AFO spiral molded to pt plas L5930 High activity knee frame L1951 spiral, IRM type, plastic or other L5950 Endo ak ultra-light material material prefab, incl. Fitting and adj. L1960 AFO pos solid ank plastic mo; custom L5960 Endo hip ultra-light materia L1970 AFO plastic molded w/ankle j L5964 addt. Endoskeleton above knee, flexible protective outer surface L1980 AFO sing solid stirrup calf custom L5966 Hip flexible cover system L1990 AFO doub solid stirrup calf; custom L5968 Multiaxial ankle w dorsiflex L2000 KAFO using fre stirr thi/calf; custom L5973 Endoskeletal ankle foot system, microprocessor, incl. power source L2005 KAFO any material, single or dbl. Upright L5976 Energy storing foot includes ankle joint custom fabricated L2010 KAFO single upright, free ankle, solid L5979 Multi-axial ankle/ft prosth stirrup L2020 KAFO dbl solid stirrup band/ L5980 Flex foot system L2030 KAFO dbl solid stirrup w/o j L5981 Flex-walk sys low ext prosth L2034 KAFO full plastic, single upright, w/wo L5987 Shank ft w vert load pylon free motion knee,custom fabricated L2036 KAFO plas doub free knee mol L5988 Vertical shock reducing pylo L2037 KAFO plas sing free knee mol L5990 addt. To lower ext. user adj. ht L2038 KAFO w/o joint multi-axis an L5999 Lower extremity prosthesis, NOC L2050 Hkafo torsion cable hip pelv; custom L6000 Par hand robin-aids thum rem Page 23 of 39

24 L2060 Hkafo torsion ball bearing j; custom L6010 Hand robin-aids little/ring L2070 Hkafo torsion unilat rot str; custom L6020 Part hand robin-aids no fing L2080 Hkafo unilat torsion cable, custom L6050 Wrst MLd sck flx hng tri pad L2090 Hkafo unilat torsion ball br, custom L6055 Wrst mold sock w/exp interfa L2106 AFO tib fx cast plaster mold, custom L6100 Elb mold sock flex hinge pad L2108 AFO tib fx cast molded to pt L6110 Elbow mold sock suspension t L2116 Afo tibial fracture rigid L6120 Elbow mold doub splt soc ste L2126 Kafo fem fx cast thermoplas L6130 Elbow stump activated lock h L2128 Kafo fem fx cast molded to p L6200 Elbow mold outsid lock hinge L2132 Kafo femoral fx cast soft L6205 Elbow molded w/ expand inter L2134 Kafo fem fx cast semi-rigid L6250 Elbow inter loc elbow forarm L2136 Kafo femoral fx cast rigid L6300 Shlder disart int lock elbow L2232 Addt. To lower extremity orthosis, L6310 Shoulder passive restor comp rocker bottom, custom fabricated only L2280 Molded inner boot L6320 Shoulder passive restor cap L2330 Lacer molded to patient, custom L6350 Thoracic intern lock elbow L2340 Pre-tibial shell molded to p L6360 Thoracic passive restor comp L2350 Prosthetic type socket molded L6370 Thoracic passive restor cap L2510 Th/wght bear quad-lat brim m L6380 Postop dsg cast chg wrst/elb L2520 Th/wght bear quad-lat brim custom L6382 Postop dsg cast chg elb dis/ L2525 Th/wght bear m-l brim mo L6384 Postop dsg cast chg shlder/t L2526 Th/wght bear m-l brim cu L6400 Below elbow prosth tiss shap L2540 Thigh/wght bear lacer molded L6450 Elb disart prosth tiss shap L2627 Plastic mold recipro hip & c L6500 Above elbow prosth tiss shap L2628 Metal frame recipro hip & ca L6550 Shldr disar prosth tiss shap L2768 Orthotic side bar, Disconnect device, L6570 Scap thorac prosth tiss shap each L2861 addt. to lower ext-joint, knee or ankle, L6580 Wrist/elbow bowden cable mol custom only, each L2999 Lower extremity orthosis NOS L6582 Wrist/elbow bowden cbl dir f L3060 Foot arch support, removable, L6584 Elbow fair lead cable molded premolded, longitudinal & horizontal, each L3201 Oxford w supinator/pronator inf each L6586 Elbow fair lead cable dir fo L3202 Oxford w supinator/pronator child each L6588 Shdr fair lead cable molded L3203 Oxford w supinator/pronator jun each L6590 Shdr fair lead cable direct L3204 Hightop w supp/pronator infant each L6611 Addt. To upper ext. prosthesis, ext. pwr switch addt. L3206 Hightop w supp/pronator child each L6623 Spring-asst. rot wrst w/ latch L3207 Hightop w supp/pronator junior each L6624 Upper ext. addt. Flex. Ext rotation wrist L3208 Surgical boot, each infant L6638 upper ext addt. To prosth. Electric locking only for use with manually powered elbow Page 24 of 39

25 L3209 Surgical boot, each child L6686 Suction socket L3211 Surgical boot, each junior L6689 Frame typ socket shoulder di L3212 Benesch boot pair infant L6690 Frame typ sock interscap-tho L3213 Benesch boot pair child L6693 Locking elbow forearm cntrbal L3214 Benesch boot pair junior L6694 Add. To upper ext. pros.,for use with locking mechanism L3215 Orthopedic ftwear ladies oxf each L6695 Add. To upper ext. pros., not for use with locking mechanism, custom L3216 Orthopedic ftwear ladies depth each L6696 Add. To upper ext. pros., congenital or atypical traumatic amputees, initial only L3217 Ladies shoes hightop depth each L6697 Add. To upper ext. pros., other than congenital or traumatic amputees, initial only L3219 Orthopedic mens shoes oxford each L6707 term dev hook, mech vol closing, any material, any size, lined or unlined L3221 Orthopedic mens shoes dpth each L6708 term dev, hand, mech vol opening, any material, any size L3222 Mens shoes hightop depth inl each L6709 term dev hand, mech vol. closing, any material, any size L3224 Woman's shoe oxford brace each L6712 Terminal device, hook,mechanical vol. closing, any material, any size, lined or unlined, Pediatric, each L3225 Man's shoe oxford brace each L6713 Terminal device, hand, mechanical, vol. opening, any material, any size,lined or unlined, Pediatric, each L3230 Custom shoes depth inlay each L6714 Terminal device, mechanical, vol. closing, any material, any size, Pediatric, each L3250 Custom mold shoe remov prost each L6721 terminal device, hook or hand, hvy, dty., mechanical, vol.opening, any material, any size, lined or unlined, each L3251 Shoe molded to pt silicone s each L6722 Terminal device, hook or hand, heavy duty, mechanical, vol. closing, any material, any size, lined or unlined, each L3252 Shoe molded plastazote cust each L6881 Automatic grasp, addt. To upper limb elect. Prosth. Terminal device L3253 Shoe molded plastazote cust each L6882 Microprocessor control feature, addt. To upper limb prosth. Terminal device L3254 Orth foot non-std size/w L6895 Custom glove L3255 Orth foot non-std size/w L6900 Hand restorat thumb/1 finger L3257 Orth foot add charge split L6905 Hand restoration multiple fi L3330 Lift elevation, metal extension, (skate) each L6910 Hand restoration no fingers Page 25 of 39

26 L3649 orthopedic shoe modification NOS L6915 Hand restoration replacmnt g L3671 Shoulder othosis, cap design w/o joints L6920 Wrist disarticul switch ctrl L3702 elbow orthosis w/o joints, may include soft interface, straps, custom fabricated incl. fitting & adj. L6925 Wrist disart myoelectronic c L3720 Forearm/arm cuffs free motio L6930 Below elbow switch control L3730 Forearm/arm cuffs ext/flex a L6935 Below elbow myoelectronic ct L3740 Cuffs adj lock w/ active con L6940 Elbow disarticulation switch L3763 elbow wrist hand orthosis rigid w/o L6945 Elbow disart myoelectronic c joints custom fab incl. fitting & adj. L3806 WHFO, incl. 1 or more nontorsion joints. L6950 Above elbow switch control Custom L3808 WHFO, rigid w/o joints, custom, L6955 Above elbow myoelectronic ct L3891 Addt. to upper ext. joint, wrist, or L6960 Shldr disartic switch contro elbow, custom fabricated only, each L3900 Hinge extension/flex wrist/f L6965 Shldr disartic myoelectronic L3901 Hinge ext/flex wrist finger L6970 Interscapular-thor switch ct L3904 Whfo electric custom fitted L6975 Interscap-thor myoelectronic L3905 wrist/hand orthosis custom L7007 elect. Hand, myoelectric or switch, adult L3906 Wrist hand orthosis, w/o joints, custom L7008 elect. Hand, myoelectric or switch, ped L3907 Whfo wrist gauntlt thmb spica L7009 elect hook, switch or myoelect, adult L3913 Hand finger orthosis, w/o joints, may include soft interface, straps, custom fabricated, incl fitting & adjustment, each L7040 Prehensile actuator switch controlled L3927 L3933 L3956 Finger orthosis, PIP/DIP, non-torsion w/o joint/spring, ext./flex., pre-fab, incl fitting & adj., each Finger orthosis, w/o joints, may include soft interface, custom fabricated, incl. fitting & adjustment, each addt. Of joint to upper ext orth. any material, per joint L7045 L7170 L7180 Electric hook, switch or myoelectric controlled, pediatric Electronic elbow hosmer swit Electronic elbow utah myoele L3960 Sewho airplan desig abdu pos L7181 electronic elbow, sim. Control of elbow and terminal device L3962 Sewho erbs palsey design abd L7185 electronic elbow, sim. Variety Village or equal switch control L3964 Seo mobile arm sup att to wc L7186 Electron elbow child switch L3965 Arm supp att to wc rancho ty L7190 Elbow adolescent myoelectron L3966 Mobile arm supports reclinin L7191 Elbow child myoelectronic ct L3968 Friction dampening arm supp L7260 Electron wrist rotator otto L3969 Monosuspension arm/hand supp L7261 Electron wrist rotator utah L3971 SEHWO, shoulder cap design, custom fabricated L7266 Servo control steeper or equ Page 26 of 39

27 L3999 Upper limb orthosis, not otherwise L7272 Analogue control unb or equa specified L4000 Repl girdle milwaukee orth L7274 Proportional ctl 12 volt uta L4002 Replacement strap, any orthosis, L7499 Upper extremity prosthesis NOS includes all components, any lgth., any type L4010 Replace trilateral socket brim L7500 Prosthetic dvc repair hourly L4020 Replace quadlat socket brim L7510 Repair of prosthetic device, minor parts L4030 Replace socket brim cust fit L7520 Repair prosthetic device, labor component, per 15 min L4040 Replace molded thigh lacer L7600 Prosthetic donning sleeve, any material L4050 Replace molded calf lacer L7900 Vacuum erection system L4205 Repair orthotic device per 15 min labor L8000 Mastectomy bra - 5 per year L4210 repair or replace minor parts L8001 Breast prosthesis, masectomy bra with integrated breast prothesis form, unilateral - 5 per year L5000 Sho insert w arch toe filler L8002 Breast prosthesis, masectomy bra with integrated breast prothesis form, bilateral - 5 per year L5010 Mold socket ank hgt w/ toe f L8020 Mastectomy form - 2 per year L5020 Tibial tubercle hgt w/ toe f L8030 Breast prosthesis silicone/e - 2 per year L5050 Ank symes mold sckt sach ft L8031 Breast prosthesis, silicone or equal, with intergral adhesive, each L5060 Symes met fr leath socket ar L8035 Custom breast prosthesis L5100 Molded socket shin sach foot L8039 Breast prosthesis, NOS L5105 Plast socket jts/thgh lacer L8040 Nasal prothesis, provided by a nonphysician L5150 Mold sckt ext knee shin sach L8041 Midfacial prothesis, provided by a nonphysician L5160 Mold socket bent knee shin s L8042 Orbital prothesis, provided by a nonphysician L5200 Knee sing axis fric shin sach L8043 Upper facial prosthesis, provided by a non-physician L5210 No knee/ankle joints w/ ft b L8044 Hemi-facial prosthesis, provided by a non-physician L5220 No knee joint with artic ali L8045 Prosthetic External Ear provided by a non-physician L5230 Fem focal defic constant fri L8046 Partial facial prosthesis, provided by a non-physician L5250 Hip canadian sing axi cons fric L8047 Nasal septal prosthesis, provided by a non-physician L5270 Tilt table locking hip sing L8048 Unspecified Maxillofacial Prosthesis, by a non-physician L5280 Hemipelvect canadian sing axis L8049 Repair or modification of maxillofacial prosthesis, by a non-physician Page 27 of 39

28 L5301 L5311 L5321 L5331 L5341 Below Knee molded socket, shin each foot, endosketal system Knee disarticulation, molded socket, external knee joints, shin,sach foot endo Above Knee, molded socket, open end, sach foot, endoskelttal system, single axis knee Hip disarticulation, Canadian type, molded socket endoskeletal system, hip joint, single Hemipelvectomy, Canadian type, molded socket, endoskeletal hip joint single axis knee L8499 L8500 L8501 L8505 L8619 Unlisted Misc prosthetic service artifical larynx Tracheostomy speaking valve Artificial larynx replacement battery/accessory, any type, each cochlear implant external speech processor replacement L5400 Postop dress & 1 cast chg bk L8627 Cochlear implant, external speech processor, component, replacement L5410 Postop dsg bk ea add cast ch L8628 Cochlear implant, external controller component, replacement L5420 Postop dsg & 1 cast chg ak/d L8629 Transmitting coil and cable, integrated for use with cochlear implant device, replacement L5430 Postop dsg ak ea add cast ch L8691 auditory osseointegrated dev, ext. sound replacer, repl only L5450 Postop app non-wgt bear dsg AUTHORIZATION NOT REQUIRED HCPCS Description HCPC Description L0120 Cerv flexible non-adjustable S L3670 Acromio/clavicular canvas&we L0140 Cervical semi-rigid adjustab L3675 Canvas vest SO L0150 Cerv semi-rig adj molded chn L3710 Elbow elastic with metal joi L0160 Cerv semi-rig wire occ/mand L3760 Elbow orthosis, adj position locking joints, prefab, inc fitting and adj L0172 Cerv col thermplas foam 2 piece L3762 Elbow orthosis rigid, w/o joints, prefab, soft interface, incl. Fitting/adj. L0174 Cerv col foam 2 piece w thor L3807 WHFO w/o joints, prefab includes fitting and adjustments any type L0180 Cer post col occ/man sup adj L3908 Wrist cock-up non-molded L0190 Cerv collar supp adj cerv ba - 1 Per Year L3912 Flex glove w/elastic finger * L0200 Cerv col supp adj bar & thor - 1 per L3915 WHFO, rigid with 1 or more joints, Page 28 of 39

29 year * prefab, L0450 TLSO flexible, provides trunk support, uper thoracic region, prefab L3917 hand orthosis, metacarpal fracture orthosis, prefab, incl fitting and adj. L0454 TLSO, Flexible, provides trunk support, sacrococcygeal juntion to T-9, prefab L3923 Hand finger orthosis, without joint, prefab, inc fitting and adj L0466 TLSO Sagittal control, prefab L3925 Finger orthosis, PIP/DIP, non-torsion joint/spring, ext./flex., pre-fab, incl fitting & adj., each L0468 TLSO sagittal-coronol control, rigid posterior frame - 1 per year * L3929 Hand finger orthosis, incl. 1 or more nontorsion joints, turnbuckles, elastic bands/spring, straps, pre-fab, incl. fitting & adj., each L0470 TLSO triplanar control - 1 per year * L3931 Wrist, hand, finger orthosis, incl. 1 or more nontorsion joints,turnbuckles, elastic bands/springs, straps, pre-fab, incl. fitting & adj., each L0472 TLSO, triplanar control, hyperextension L3970 Elevat proximal arm support prefab - 1 per year * L0490 TLSO sagittal coronal control one piece prefab L3972 Offset/lat rocker arm w/ ela L0492 TLSO 3 rigid plastic shells, pre fab - 1 per year * L3974 Mobile arm support supinator L0621 Sacroiliac orthosis, flexible, pre fab L3980 Upp ext fx orthosis humeral L0625 Lumbar orthosis, flexible, pre fab L3982 Upper ext fx orthosis rad/ul L0626 Lumbar orthosis, sagittal control, pre L3984 Upper ext fx orthosis wrist fab L0627 Lumbar orthosis, sagittal control with rigid ant./post. Panels, pre fab L3995 Add. To upper ext. sock, fracture, or equal, each L0628 Lumbar-sacral orthosis, flexible, pre fab L4045 Replace non-molded thigh lac L0630 Lumbar-sacral orthosis, sag. Control, L4055 Replace non-molded calf lace pre fab L0633 Lumbar-sacral orthosis, sag. Control, L4060 Replace high roll cuff rigid post., pre fab L0970 Tlso corset front L4070 Replace prox & dist upright L0972 Lso corset front L4080 Repl met band kafo-afo prox L0974 Tlso full corset L4090 Repl met band kafo-afo calf/ L0976 Lso full corset L4100 Repl leath cuff kafo prox th L0978 Axillary crutch extension L4110 Repl leath cuff kafo-afo cal L0980 Peroneal straps pair L4130 Replace pretibial shell L0982 Stocking supp grips set of 4 L4350 Pneumatic ankle cntrl splint L0984 Protective body sock each L4360 Pneumatic walking splint L1010 Ctlso axilla sling L4370 Pneumatic full leg splint L1020 Kyphosis pad L4380 Pneumatic knee splint L1025 Kyphosis pad floating L4386 Non-pneumatic walking boot L1030 Lumbar bolster pad L4394 Replacement Foot Drop Splint Page 29 of 39

30 L1040 Lumbar or lumbar rib pad L4396 Static AFO L1050 Sternal pad L4398 Foot drop splint recumbent L1060 Thoracic pad L5617 AK/BK self-aligning unit ea L1070 Trapezius sling L5618 Test socket symes L1080 Outrigger L5620 Test socket below knee L1085 Outrigger bil w/ vert extens L5622 Test socket knee disarticula L1090 Lumbar sling L5624 Test socket above knee L1100 Ring flange plastic/leather L5626 Test socket hip disarticulat L1110 Ring flange plas/leather molded to patient L5628 Test socket hemipelvectomy L1120 Covers for upright each L5629 Below knee acrylic socket L1210 Lateral thoracic extension L5630 Syme typ expandabl wall sckt L1220 Anterior thoracic extension L5631 Ak/knee disartic acrylic soc L1230 Milwaukee type superstructur L5632 Symes type ptb brim design s L1240 Lumbar derotation pad L5634 Symes type poster opening so L1250 Anterior asis pad L5636 Symes type medial opening so L1260 Anterior thoracic derotation pad L5637 Below knee total contact L1270 Abdominal pad L5638 Below knee leather socket L1280 Rib gusset (elastic) each L5640 Knee disarticulat leather so L1290 Lateral trochanteric pad L5642 Above knee leather socket L1600 Abduct hip flex frejka w cvr L5644 Above knee wood socket L1610 Abduct hip flex frejka covr L5646 Below knee air cushion socket L1620 Abduct hip flex pavlik harne L5650 Tot contact ak/knee disart s L1630 Abduct control hip semi-flex L5652 Suction susp ak/knee disart L1640 Pelv band/spread bar thigh c L5653 Knee disart expand wall sock L1650 HO abduction hip adjustable L5654 Socket insert symes L1660 HO abduction static plastic L5655 Socket insert below knee L1810 KO elastic with joints L5656 Socket insert knee articulat L1820 KO elas w/ condyle pads & jo L5658 Socket insert above knee L1830 KO immobilizer canvas longit L5661 Multi-durometer symes L1831 KO locking knee joint pre fab incl. L5665 Multi-durometer below knee Fitting and adj. L1847 KO adjustable w air chambers L5666 Below knee cuff suspension L1850 KO swedish type L5668 Socket insert w/o lock lower L1900 AFO sprng wir drsflx calf bd L5671 Addition to lower extremity, below knee/above knee suspension locking mechanism L1902 AFO ankle gauntlet L5672 Bk removable medial brim sus L1906 AFO multiligamentus ankle su L5676 Bk knee joints single axis pair L1910 AFO sing bar clasp attach sh L5677 Bk knee joints polycentric pair L1920 AFO sing upright w/ adjust s L5678 Bk joint covers pair L1930 AFO plastic or other material, includes L5680 Bk thigh lacer non-molded Page 30 of 39

31 fitting & adjustment L1971 plastic or other material w/ankle joint, L5684 Bk fork strap prefab, incl. Fitting and adj. L2035 KAFO plastic pediatric size L5685 Addt. To lower ext. orthosis, below knee, susp./sealing sleeve, any mat. Each L2040 Hkafo torsion bil rot straps L5686 below knee back check extension control L2112 AFO tibial fracture soft, pre-fab L5688 Bk waist belt webbing L2114 AFO tib fx semi-rigid, pre-fab L5690 Bk waist belt padded and lin L2180 Plas shoe insert w ank joint L5692 Ak pelvic control belt light L2182 Drop lock knee L5694 Ak pelvic control belt pad/l L2184 Limited motion knee joint L5695 Ak sleeve susp neoprene/equa L2186 Adj motion knee jnt lerman t L5696 Ak/knee disartic pelvic join L2188 Quadrilateral brim L5697 Ak/knee disartic pelvic band L2190 Waist belt L5698 Ak/knee disartic silesian ba L2192 Pelvic band & belt thigh fla L5699 Shoulder harness L2200 Limited ankle motion ea jnt L5710 Kne-shin exo sng axi mnl loc L2210 Dorsiflexion assist each joi L5711 Knee-shin exo mnl lock ultra L2220 Dorsi & plantar flex ass/res L5712 Knee-shin exo frict swg & st L2230 Split flat caliper stirr & p L5714 Knee-shin exo variable frict L2240 Addt. To lower extremity orthosis, L5785 Exoskeletal bk ultralt mater round caliper & plate attachment L2250 Foot plate molded stirrup at L5810 Endoskel knee-shin mnl lock L2260 Reinforced solid stirrup L5812 Endo knee-shin frct swg & st L2265 Long tongue stirrup L5850 Endo ak/hip knee extens assi L2270 Varus/valgus strap padded/li L5855 Mech hip extension assist L2275 Plastic mod low ext pad/line L5910 Addt. Endoskeleton, below knee, alignable system L2300 Abduction bar jointed adjust L5920 Endo ak/hip alignable system L2310 Abduction bar-straight L5925 Above knee manual lock L2320 Non-molded lacer L5940 Endo bk ultra-light material L2335 Anterior swing band L5962 Below knee flex cover system L2360 Extended steel shank L5970 Foot external keel sach foot L2370 Patten bottom L5971 All lower extremity prosthesis, SACH foot, replacement only L2375 Torsion ank & half solid sti L5972 Flexible keel foot L2380 Torsion straight knee joint; L5974 Foot single axis ankle/foot L2385 Straight knee joint heavy du L5975 Combo ankle/foot prosthesis L2387 Addt. to lower extremity, polycentric L5978 Ft prosth multiaxial ankl/ft knee joint, for custom fabricated KAFO, each joint L2390 Offset knee joint each L5982 Exoskeletal axial rotation Page 31 of 39

32 L2395 Offset knee joint heavy duty L5984 Endoskeletal axial rotation, w/wo adjustability L2397 Suspension sleeve lower ext L5985 Lwr ext dynamic prosth pylon L2405 Knee joint drop lock ea jnt L5986 Multi-axial rotation unit L2415 Knee joint cam lock each joi L6386 Postop ea cast chg & realign L2425 Knee disc/dial lock/adj flex L6388 Postop applicat rigid dsg on L2430 Knee jnt ratchet lock ea jnt L6600 Polycentric hinge pair L2492 Knee lift loop drop lock rin L6605 Single pivot hinge pair L2500 Thi/glut/ischia wgt bearing L6610 Flexible metal hinge pair L2530 Thigh/wght bear lacer non-mo L6615 Disconnect locking wrist uni L2550 Thigh/wght bear high roll cu L6616 Disconnect insert locking wr L2570 Hip clevis type 2 posit jnt L6620 Flexion-friction wrist unit L2580 Pelvic control pelvic sling L6625 Rotation wrst w/ cable lock L2600 Hip clevis/thrust bearing fr L6628 Quick disconn hook adapter o L2610 Hip clevis/thrust bearing lo L6629 Lamination collar w/ couplin L2620 Pelvic control hip heavy dut L6630 Stainless steel any wrist L2622 Hip joint adjustable flexion L6632 Latex suspension sleeve each L2624 Hip adj flex ext abduct cont L6635 Lift assist for elbow L2630 Pelvic control band & belt u L6637 Nudge control elbow lock L2640 Pelvic control band & belt b L6640 Shoulder abduction joint pai L2650 Pelv & thor control gluteal L6641 Excursion amplifier pulley t L2660 Thoracic control thoracic ba L6642 Excursion amplifier lever ty L2670 Thorac cont paraspinal uprig L6645 Shoulder flexion-abduction joint, each L2680 Thorac cont lat support upri L6650 Shoulder universal joint, each L2750 Plating chrome/nickel pr bar L6655 Standard control cable extra L2755 Addt. Lower ext.,high strength, custom L6660 Heavy duty control cable fab. Only L2760 Extension per extension per L6665 Teflon or equal cable lining L2780 Non-corrosive finish per bar L6670 Hook to hand cable adapter L2785 Drop lock retainer each L6672 Harness chest/shlder saddle L2795 Knee control full kneecap L6675 Harness figure of 8 sing con L2800 Knee cap medial or lateral p L6676 Harness figure of 8 dual con L2810 Knee control condylar pad L6680 Test sock wrist disart/bel e L2820 Soft interface below knee se L6682 Test sock elbw disart/above L2830 Soft interface above knee se L6684 Test socket shldr disart/tho L2840 Tibial length sock fx or equ L6687 Frame typ socket bel ow elbow or wrist L2850 Femoral lgth sock fx or equa L6688 Frame typ sock above elbow or elbow disarticulation L3000 foot insert Berkeley shell, each L6691 Removable insert each L3001 foot insert Spenco, each L6692 Silicone gel insert or equal L3002 foot insert, Plastazote, each L6698 Add. To upper ext. pros., lock mechanism, excludes socket insert Page 32 of 39

33 L3003 foot insert, Silicone gel, each L6703 term. Device, passive hand mitt, any material, any size L3010 Longitudinal Arch support each L6704 term. Device, sport/rec/work, any material, any size L3020 Foot longitud/metatarsal supp L6706 term dev hook, mech vol opening, any material, any size L3030 Foot arch support remov prem L6711 Terminal device, hook, mechanical, vol. opening, any material, any size, lined or unlined, Pediatric, each L3040 Foot arch support remov premolded longitudinal, each L6805 Modifier wrist flexion unit addt to terminal device L3100 Hallus-valgus night dynamic splint L6810 Addt to terminal device, precision pinch device L3140 Abduction rotation bar shoe L6890 Production glove L3150 Abduction rotation bar w/o shoe L7360 Six volt battery, each L3160 Shoe styled postioning device L7362 Battery charger, six volt, each L3170 Foot plastic heel stablizer L7364 Twelve volt battery, each - 2 per year * L3260 Ambulatory surgical boot each L7366 Battery charger 12 volt each - 1 per 4 years * L3265 Plastazole sandal each L7367 lithium ion battery replacement L3300 Lift, Elevation Heel, Tapered to Metata L7368 Lithium battery charger - 1 per 4 years * L3310 Shoe lift elev heel/sole neo L7400 Addt. To upper ext. prosth. Ultralight material L3320 shoe lift elev heel/sole cor L7401 Addt. To upper ext. prosthesis above elbow disart. Ultralight material L3332 Shoe lift inside tapered up to 1/2 inch L7403 Addt. To upper ext. prosth. acrylic material L3334 Shoe, lift elevation, heel, per inch, each L7404 addt. To upper ext prosth. Above elbow disart. Acrylic L3340 shoe wedge sach L8010 Mastectomy sleeve L3350 shoe sole wedge L8015 Ext breast prosthesis garment L3360 shoe sole wedge outside sole L8300 Truss single w/ standard pad L3370 shoe sole wedge between sole L8310 Truss double w/ standard pad L3380 shoe clubfoot wedge L8320 Truss addition to std pad wa L3390 shoe outflare wedge L8330 Truss add to std pad scrotal L3400 shoe metarsal bar wedge L8400 Sheath below knee L3410 shoe metarsal bar between L8410 Sheath above knee L3420 full sole/heel wedge btween L8415 Sheath upper limb L3430 shoe heel count plast reinforc L8417 Prosthetic sheath/sock, incl. gel cushion layer, below knee or above knee, each L3440 heel leather reinforced L8420 Prosthetic sock multi ply BK L3450 shoe heel sach cushion type L8430 Prosthetic sock multi ply AK Page 33 of 39

34 L3455 shoe heel new leather standard L8435 Pros sock multi ply upper lm L3460 shoe heel new rubber standard L8440 Shrinker below knee L3465 shoe heel thomas with wedge L8460 Shrinker above knee L3470 shoe heel thomas extend to B L8465 Shrinker upper limb L3480 shoe heel pad &depress for L8470 Pros sock single ply BK L3485 shoe heel pad removeable for L8480 Pros sock single ply AK L3500 ortho shoe add leather insol L8485 Pros sock single ply upper l L3510 orthopedic shoe add rub insl L8507 Tracheo-esophageal voice prosthesis, patient inserted, any type L3520 ortho shoe add felt w leather insol L8509 Tracheo-esophageal voice prosthesis, inst. by lic. Health care provider, any type L3530 ortho shoe add half sole L8510 Voice Amplifier L3540 ortho shoe add full sole L8511 Insert for Indwelling T/E prosthesis with or W/O valve replacement each L3550 ortho shoe add standard toe tap L8512 Gelatin capsules or equ. use with T/E prosthesis replacement only per 10 L3560 ortho shoe add horseshoe toe tap L8513 Cleaning device used with T/E prosthesis replacement only each L3570 ortho shoe add instep extension L8514 T/E puncture dilator replacement only each L3580 ortho shoe add instep velcro clos L8515 gelatin capsule application device for use with TE voice prosthesis, each L3590 ortho shoe convert firm to soft count L8615 Headset/Headpiece for use with cochlear implant device, replacement L3595 ortho shoe add march bar L8616 microphone for use with cochlear implant device, replacement L3600 Trans shoe calip plate exist L8617 transmitting coil for use with cochlear implant device, replacement L3610 Trans shoe caliper plate new L8618 transmitter cable for use with cochlear implant device, replacement L3620 Trans shoe solid stirrup existing L8621 Zinc air battery for use with cochlear implant device, each L3630 Trans shoe solid stirrup new L8622 Alkaline batt. For use with coch. Imp. Device, any size,each L3640 Shoe Dennis Browne splint both L8623 Lithium ion battery coch. imp. Device speech proc.other than Ear level, ea L3650 Shlder fig 8 abduct restrain L8624 Lithium ion battery for coch. imp. Device speech proc. Ear level, each L3660 Abduct restrainer canvas&web L8695 ext recharging sys for battery(ext) for use with implantable neurostimulator Page 34 of 39

35 Appendix C Ostomy Supplies Any request that exceeded $ will require prior authorization. AUTHORIZATION REQUIRED A4421 Ostomy supply, miscellaneous Authorization is required A4465 Non elastic binder for extremity Authorization is required A4466 Garment, belt, sleeve or other covering, elastic or similar Authorization is required stretchable material, any type, each A4483 Moisture exchanger, disposable, for use with invasive mechanical Authorization is required ventilation, each A4600 sleeve for intmt. Limb compression device, replac. only Authorization is required A4601 Lithium ion battery for non-prosthetic use, repl. Only Authorization is required A4649 Surgical Supply, Miscellaneous Authorization is required AUTHORIZATION REQUIRED IF QUANTITY LIMIT IS EXCEEDED A4366 Ostomy vent, any type, each Authorization required > 1 per calendar month A4367 Ostomy belt Authorization required > 1 per calendar month A4400 Ostomy irrigation set Authorization required > 1 per calendar month A4404 Ostomy ring each Authorization required > 10 per calendar month A4362 Solid skin barrier Authorization required > 20 per calander month A4398 Ostomy irrigation bag Authorization required > 4 per year A4399 Ostomy irrig cone/cath w brs Authorization required > 4 per year A4402 Lubricant price is per oz. 1 oz.=1 unit Authorization required > 4 oz per calendar month A4397 Irrigation supply sleeve Authorization required > 4 per calendar month A4361 Ostomy face plate Authorization required > 6 per year A4416 Ostomy pouch, closed, w/barrier att. W/filter 1 pc. Each Authorization required > 60 per calendar month A4417 Ostomy pouch,closed, w/barrier att.,w/built-in convexity, w/filter 1 pc, each Authorization required > 60 per calendar month A4418 Ostomy pouch,closed, w/o barrier att. W/filter 1 pc. Each Authorization required > 60 per calendar month A4419 Ostomy pouch, closed, use on barrier w/non-lock flange,w/filter 2pc, each Authorization required > 60 per calendar month A4420 Ostomy pouch, closed, use on barrier with lock flange 2 pc, each Authorization required > 60 per calendar month Page 35 of 39

36 A4423 Ostomy pouch closed, 2 pc. Locking flange, each Authorization required > 60 per calendar month A4424 Ostomy pouch, drainable,w/barrier 1 pc, each Authorization required > 60 per calendar month A4425 Ostomy pouch drainable, non-locking flange 2 pc each Authorization required > 60 per calendar month A4426 Ostomy pouch, drainable, with locking flange, 2 pc. Each Authorization required > 60 per calendar month A4427 Ostomy pouch, drainable, use on barrier w/locking flange, w/filter 2 pc, each Authorization required > 60 per calendar month A4428 Electrodes, apnea monitor, per pair Authorization required > 60 per calendar month A4429 Ostomy pouch, urinary w/convexity, faucet type tap, each Authorization required > 60 per calendar month A4430 ostomy pouch urinary, ext. wear, convexity, faucet tap, each Authorization required > 60 per calendar month A4431 ostomy pouch, urinary, w/barrier, faucet type tap, w/valve ea. Authorization required > 60 per calendar month A4432 ostomy pouch, urinary, non-locking flange, faucet type, ea. Authorization required > 60 per calendar month A4433 ostomy pouch, urinary, w/locking flange, ea. Authorization required > 60 per calendar month A4434 ostomy pouch, urinary, w/locking flange, w/faucet type tap ea. Authorization required > 60 per calendar month A4624 Tracheal suction tube Authorization required > 91 per calendar month A4625 Trach care kit for new trach Authorization required if > 1 per calendar month A5082 Continent stoma catheter Authorization required if > 1 per calendar month A5093 Ostomy accessory convex inse Authorization required if > 10 per calendar month A4626 Tracheostomy cleaning brush Authorization required if > 2 per calendar month A5061 Pouch drainable w barrier at Authorization required if > 20 per calendar month A5062 Drnble ostomy pouch w/o barr Authorization required if > 20 per calendar month A5063 Drain ostomy pouch w/flange Authorization required if > 20 per calendar month A5071 Urinary pouch w/barrier Authorization required if > 20 per calendar month A5072 Urinary pouch w/o barrier Authorization required if > 20 per calendar month A5073 Urinary pouch on barr w/flng Authorization required if > 20 per calendar month Page 36 of 39

37 A4623 Tracheostomy inner cannula Authorization required if > 31 per calendar month A5055 Stoma cap Authorization required if > 31 per calendar month A5081 Continent stoma plug Authorization required if > 31 per calendar month A4455 Adhesive remover per ounce Authorization required if > 32 ounces A5051 Pouch clsd w barr attached Authorization required if > 60 per calendar month A5052 Clsd ostomy pouch w/o barr Authorization required if > 60 per calendar month A5053 Clsd ostomy pouch faceplate Authorization required if > 60 per calendar month A5054 Clsd ostomy pouch w/flange Authorization required if > 60 per calendar month AUTHORIZATION NOT REQUIRED A4392 Urinary pouch w st wear barr No authorization required A4363 Ostomy clamp, any type, each No authorization required A4364 Adhesive, liquid or equal, any type, per ounce No authorization required A4365 Ostomy adhesive remover wipe No authorization required A4368 Ostomy filter No authorization required A4369 Skin barrier liquid per oz No authorization required A4371 Skin barrier powder per oz No authorization required A4372 Ostomy Skin barrier solid 4x4 equiv No authorization required A4373 Skin barrier with flange No authorization required A4375 Drainable plastic pch w fcpl No authorization required A4376 Drainable rubber pch w fcplt No authorization required A4377 Drainable plstic pch w/o fp No authorization required A4378 Drainable rubber pch w/o fp No authorization required A4379 Urinary plastic pouch w fcpl No authorization required A4380 Urinary plastic pouch w/o fp No authorization required A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each No authorization required A4382 Urinary hvy plstc pch w/o fp No authorization required A4383 Urinary rubber pouch w/o fp No authorization required A4384 Ostomy faceplt/silicone ring No authorization required A4385 Ost skn barrier sld ext wear No authorization required A4387 Ost clsd pouch w att st barr No authorization required A4388 Drainable pch w ex wear barr No authorization required A4389 Drainable pch w st wear barr No authorization required A4390 Drainable pch ex wear convex No authorization required A4391 Urinary pouch w ex wear barr No authorization required A4393 Urine pch w ex wear bar conv No authorization required A4394 Ostomy pouch liq deodorant w/wo lubricant No authorization required A4395 Ostomy pouch solid deodorant No authorization required A4396 Ostomy belt with peristomal hernia support No authorization required Page 37 of 39

38 A4405 Ostomy skin barrier, non-pectin based, paste, per oz No authorization required A4406 Ostomy skin barrier, pectin based, per oz No authorization required A4407 Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4 No authorization required or < A4408 Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4 No authorization required or > A4409 Ostomy skin barrier with flange No authorization required A4410 Ostomy skin barrier, with fl, ex wear, without built in convexity, No authorization required >4x4 ea A4411 Ostomy skin barrier, solid 4x4 or eq. ext. wear, built in convexity, No authorization required each A4412 Ostomy pouch, drainable, high otpt, use on barrier w/ o filter No authorization required each A4413 Ostomy pouch, drainable, high otpt, use on barrier w/ fl with No authorization required filter ea A4414 Ostomy skin barrier, with fl, w/o built in convexity 4x4 or < No authorization required A4415 Ostomy skin barrier, with fl, w/o built in convexity 4x4 or > No authorization required A4450 Tape, non-water proof, 18 sq inches No authorization required A4452 Tape, water proof, 18 sq inches No authorization required A4456 Adhesive remover, wipes, any type, each No authorization required A4481 Tracheostoma filter No authorization required A4556 Electrodes, apnea monitor, per pair No authorization required A4557 Lead wires, apnea monitor per pair No authorization required A4558 Conductive paste or gel for use with electrical device E.G. tens No authorization required A4561 Pessary, rubber, any type No authorization required A4562 Pessary, nonrubber, any type No authorization required A4565 Slings No authorization required A4566 Canvas vest SO No authorization required A4595 TENS suppl 2 lead per month No authorization required A4604 tubing with integrated heat use with pos. airway pressure device No authorization required A4605 Tracheal suction catheter, closed system, each No authorization required A4606 Oximeter probe replacement No authorization required A4608 Transtracheal oxygen catheter, each No authorization required A4611 Heavy duty battery, Ventilator, replacement for patient owned No authorization required A4612 Battery cables No authorization required A4613 Battery charger No authorization required A4614 Hand-held PEFR meter No authorization required A4618 Breathing circuits No authorization required A4619 Face tent No authorization required A4627 Spacer, bag or reservoir for inhaler No authorization required A4628 Oropharyngeal suction cath No authorization required A4629 Tracheostomy care kit No authorization required A4630 Repl bat t.e.n.s. own by pt No authorization required A4635 Underarm crutch pad No authorization required A4636 Handgrip for cane etc No authorization required A4637 Repl tip cane/crutch/walker No authorization required Page 38 of 39

39 A4640 Alternating pressure pad No authorization required A5083 Continent device, stoma absorptive cover for continent device, No authorization required each Page 39 of 39