LCD and Policy Article Revisions Summary for December 11, 2025 - JD DME

Joint DME MAC Publication
Posted December 11, 2025

Outlined below are the principal changes to the DME MAC Local Coverage Determinations (LCDs) and Policy Articles (PAs) that have been revised and posted. The policies included are External Infusion Pumps and Knee Orthoses. Please review the entire LCDs and PAs for complete information.

External Infusion Pumps

LCD

Revision Effective Date: 01/25/2026
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Criterion I from "Levodopa-Carbidopa enteral suspension (J7340) is only covered for treatment of motor fluctuations in beneficiaries with Parkinson's disease (PD), who meet all of the following criteria (Refer to the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses.):" with four criteria listed and three non-covered patient conditions to "Infusion-based therapy (including enteral suspension) for the treatment of Parkinson's Disease will be covered if criterion 1 and either criterion 2 or 3 are met (refer to the Group 4 ICD-10 code list in the LCD-related Policy Article for applicable diagnoses):" with three criteria listed
Revised: Criterion J from "Blinatumomab (J9039) is only covered for:" with two criteria listed to "Blinatumomab (J9039) is covered for adult and pediatric beneficiaries (one month or older) who meet one of the following coverage criteria:" with three criteria listed
SUMMARY OF EVIDENCE:
Added: Information related to Blinatumomab and Foslevodopa/Foscarbidopa
ANALYSIS OF EVIDENCE:
Added: Information related to Blinatumomab and Foslevodopa/Foscarbidopa
HCPCS CODES:
Added: J7356 to Group 4 HCPCS Codes
BIBLIOGRAPHY:
Added: Information related to Blinatumomab and Foslevodopa/Foscarbidopa
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments article (A60373)

PA

Revision Effective Date: 01/25/2026
DME INFORMATION FORM (DIF):
Removed: DME INFORMATION FORM (DIF) section due to timely filing
CODING GUIDELINES:
Revised: "Claims for levodopa-carbidopa" to "Claims for levodopa-carbidopa enteral suspension"
Added: Billing information for foslevodopa/foscarbidopa injection for continuous subcutaneous infusion for October 17, 2024 through June 30, 2025
Added: Billing information for foslevodopa/foscarbidopa injection for continuous subcutaneous infusion for dates of service on or after July 1, 2025
Added: Billing information for Foslevodopa/foscarbidopa injection for continuous subcutaneous infusion
Added: Billing information for the VYAFUSER pump
Revised: "There are two alternative infusion protocols that can be used" to "There are four alternative infusion protocols that can be used" for blinatumomab
Added: Alternative infusion protocol information pertaining to beneficiaries using a 3-day infusion protocol and pertaining to beneficiaries using a 4-day infusion protocol
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: J7356 to Group 4 Paragraph

12/11/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Knee Orthoses

LCD

Revision Effective Date: 01/25/2026
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Removed: "A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related Policy Article."
Removed: "Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-related Policy Article."
Revised: "A knee orthosis, Swedish type, prefabricated (L1850) is covered for a beneficiary who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee, congenital or acquired (refer to the Group 5 ICD-10 Codes in the LCD-related Policy Article)." to "A prefabricated Swedish type knee orthosis (L1850) is covered for a beneficiary who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee, congenital or acquired (refer to the Group 5 ICD-10 Codes in the LCD-related Policy Article)."
Removed: "For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test)."
Added: "An immobilizer knee orthosis without joints (L1830) is covered for a beneficiary who has had a recent injury to or a surgical procedure on the knee(s) (refer to the Group 2 or Group 4 ICD-10 Codes in the LCD-related Policy Article)."
Added: "A knee orthosis with adjustable knee joints (L1832, L1833) is covered if one of the following criteria is met:" and information pertaining to the criterion of a recent injury to or a surgical procedure on the knee(s) and the criterion of the beneficiary being ambulatory and having knee instability
Added: "For a knee orthosis with adjustable knee joints or a prefabricated Swedish type knee orthosis (L1832, L1833, L1850), objective knee instability must be supported by documentation of the beneficiary's physical examination including the joint laxity test(s) performed (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section in the LCD-related Policy Article)."
Added: "A knee orthosis with single or double upright, adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment (L1843, L1845, L1851, L1852) is covered if one of the following criteria (1-3) is met:" and information pertaining to the criterion of the beneficiary being ambulatory and having objective knee instability, the criterion of a recent injury to or a surgical procedure on the knee(s), and a criterion of the beneficiary having a documented medial or lateral tibiofemoral osteoarthritis and meeting all criteria (a-d)
Revised: "Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented." to "Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage."
SUMMARY OF EVIDENCE:
Added: Information related to knee orthoses for osteoarthritis, pain, mobility and function
ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):
Added: Information related to knee orthoses for osteoarthritis, pain, mobility and function
BIBLIOGRAPHY:
Added: Information related to knee orthoses for osteoarthritis, pain, mobility and function
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments (A60371)

PA

Revision Effective Date: 01/25/2026
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Documentation requirements for HCPCS codes L1832, L1833, L1843, L1844, L1845, L1846, L1850, L1851, L1852
GENERAL REQUIREMENTS:
Added: HCPCS code L1820 to items coded as custom-fitted
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: HCPCS codes L1830 and L1834 to Group 4 Paragraph
Added: Group 6 Paragraph, which is "For HCPCS codes L1843, L1844, L1845, L1846, L1851 and L1852:"
Added: Group 6 Codes, which are ICD-10-CM Codes M17.0, M17.11, M17.12, M17.2, M17.31, M17.32, M17.4, M17.5, M17.9

12/11/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.