Noncovered Items - JA DME
Noncovered Items
In order for an item to be covered by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC), it must fall within a benefit category. Medicare Part B covered services processed by the DME MAC fall into the following benefit categories specified in Section 1861(s) of the Social Security Act:
Benefit Categories
- Durable medical equipment (DME)
- Prosthetic devices (artificial legs, arms, and eyes, including replacement prostheses)
- Leg, arm, back and neck braces (orthoses)
- Surgical dressings
- Immunosuppressive drugs
- Intravenous Immune Globulin
- Lymphedema Compression Treatment Items
- Therapeutic shoes for diabetics
- Oral anticancer drugs
- Oral antiemetic drugs (replacement for intravenous antiemetics)
Some items may not meet the definition of a Medicare benefit or may be statutorily excluded. In order for a beneficiary to be eligible for DME, prosthetics, orthotics, and supplies reimbursement, the reasonable and necessary requirements set out in the related Local Coverage Determination (LCD) must be met. In addition, there are statutory payment requirements specific to each policy that must be met. This criterion will be identified in individual LCD-related Policy Articles as statutorily noncovered.
The Medicare National Coverage Determinations (NCD) Manual provides the Durable Medical Equipment (DME) Reference List identifying DME items and their coverage status.
The following HCPCS codes will be denied as noncovered when submitted to the DME MAC.
| HCPCS Code | Brief Description |
|---|---|
| A4210 | Needle-free injection device, each |
| A4250 | Urine test or reagent strips or tablets (100 tablets or strips) |
| A4490 | Surgical stockings above knee length, each |
| A4495 | Surgical stockings thigh length, each |
| A4500 | Surgical stockings below knee length, each |
| A4510 | Surgical stockings full-length, each |
| A4520 | Incontinence garment, any type, (e.g. brief, diaper), each |
| A4554 | Disposable underpads, all sizes |
| A4627 | Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler |
| A6000 | Non contact wound-warming wound cover for use with the non contact wound-warming device and warming card |
| A6542 | Gradient compression stocking, custom made |
| A6543 | Gradient compression stocking, lymphedema |
| A6544 | Gradient compression stocking, garter belt |
| A9270 | Noncovered item or service |
| A9275 | Home glucose disposable monitor, includes test strips |
| A9276 | Sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply |
| A9277 | Transmitter; external, for use with interstitial continuous glucose monitoring system |
| A9278 | Receiver (monitor); external, for use with interstitial continuous glucose monitoring system |
| A9280 | Alert or alarm device, not otherwise classified |
| A9281 | Reaching/grabbing device, any type, any length, each |
| A9282 | Wig, any type, each |
| A9300 | Exercise equipment |
| B4100 | Food thickener, administered orally, per ounce |
| E0172 | Seat lift mechanism placed over or on top of toilet, and type |
| E0191 | Heel or elbow protector, each |
| E0203 | Therapeutic lightbox, minimum 10,000 lux, table top model |
| E0220 | Hot water bottle |
| E0230 | Cap or collar |
| E0231 | Non-contact wound warming device (temperature control unit, AC adapter and power cord) for use with warming card and wound cover |
| E0232 | Warming card for use with the non-contact wound warming device and non-contact wound warming wound cover |
| E0240 | Bath/shower chair, with or without wheels, any size |
| E0241 | Bath tub wall rail, each |
| E0242 | Bath tub rail, floor base |
| E0243 | Toilet rail, each |
| E0244 | Raised toilet seat |
| E0245 | Tub stool or bench |
| E0246 | Transfer tub rail attachment |
| E0247 | Transfer bench for tub or toilet with or without commode opening |
| E0248 | Transfer bench, heavy duty, for tub or toilet with or without commode opening |
| E0270 | Hospital bed, institutional type includes: oscillating, circulating and stryker frame with mattress |
| E0273 | Bed board |
| E0274 | Over-bed table |
| E0315 | Bed accessory: board, table, or support device, any type |
| E0481 | Intrapulmonary percussive ventilation system and related accessories |
| E0625 | Patient lift, bathroom or toilet, not otherwise classified |
| E0637 | Combination sit to stand system, any size including pediatric, with seatlift feature, with or without wheels |
| E0638 | Standing frame system, one position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels |
| E0641 | Standing frame system, multi-position (e.g. three-way stander), any size including pediatric, with or without wheels |
| E0642 | Standing frame system, mobile (dynamic stander), any size including pediatric |
| E0700 | Safety equipment (e.g., belt, harness or vest) |
| E0710 | Restraints, any type (body, chest, wrist or ankle) |
| E0936 | Continuous passive motion exercise device for use other than knee |
| E1300 | Whirlpool, portable (overtub type) |
| J1055 | Injection, medroxyprogesterone acetate for contraceptive use, 150 mg |
| J3520 | Edetate disodium, per 150 mg |
| J3535 | Drug administered through a metered dose inhaler |
| J3570 | Laetrile, amygdalin, vitamin B-17 |
| J8499 | Prescription drug, oral, nonchemotherapeutic, NOS |
| J8515 | Cabergoline, oral, 0.25 mg |
| L0210 | Thoracic rib belt |
| L1800 | Knee orthosis, elastic with stays, prefabricated |
| L1815 | Knee orthosis, elastic or other elastic type material, with condylar pads, prefabricated |
| L1825 | Knee orthosis, elastic knee cap, prefabricated |
| L1901 | Ankle orthosis, elastic, prefabricated |
| L3215 | Orthopedic footwear, ladies shoes, oxford, each |
| L3216 | Orthopedic footwear, ladies shoes, depth inlay, each |
| L3217 | Orthopedic footwear, ladies shoes, hightop, depth inlay, each |
| L3219 | Orthopedic footwear, mens shoes, oxford, each |
| L3221 | Orthopedic footwear, mens shoes, depth inlay, each |
| L3222 | Orthopedic footwear, mens shoes, hightop, depth inlay, each |
| L3651 | Shoulder orthosis, single shoulder, elastic, prefabricated |
| L3652 | Shoulder orthosis, double shoulder, elastic, prefabricated |
| L3700 | Elbow orthosis elastic with stays, prefabricated |
| L3701 | Elbow orthosis, elastic, prefabricated |
| L3909 | Wrist orthosis, elastic, prefabricated |
| L3911 | Wrist hand finger orthosis, elastic, prefabricated |
| L7600 | Prosthetic donning sleeve, any material, each |
| L7900 | Male Vacuum Erection System |
| L7902 | Tension Ring, for vacuum erection device, any type, replacement only, each |
| Q0144 | Azithromycin dehydrate, oral, capsules/powder, 1 gram |
| Q5108 | Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg |
| Q5110 | Injection, filgrastim-aafi, biosimilar, (nivestym), 1 mg |
| V2025 | Deluxe frame |
| V2600 | Hand held low vision aids and other nonspectacle mounted aids |
| V2610 | Single lens spectacle mounted low vision aids |
| V2615 | Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system |
| V2702 | Deluxe lens feature |
| V2760 | Scratch resistant coating, per lens |
| V5336 | Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid) |
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Last Updated Feb 27 , 2024
