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Same or Similar Chart

Replacement - The definition of replacement is found in the Medicare Benefit Policy Manual (CMS Pub. 100-02), Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entirely identical or nearly identical item when the original item is lost, stolen, or irreparably damaged. Further direction on replacement is included in the Standard Documentation Requirements Article A55426 on the CMS website.

Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL for durable medical equipment (DME) is determined through program instructions. In the absence of program instructions, Medicare Administrative Contractors (MACS) may determine the RUL of equipment, but in no case can it be less than 5 years.  

  • Computation of the RUL is based on when the equipment is delivered to the beneficiary, not the age of the equipment.
  • Replacement due to wear is not covered during the RUL of the equipment.
  • During the RUL, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary.

Not Covered - The items listed below are not covered for replacement.

  • Charges for the replacement of oxygen equipment
  • Items that require frequent and substantial servicing
  • Inexpensive or routinely purchased items which are being rented

Replacement of Prosthetics - There are special rules for the replacement of artificial arms, lower limbs, and eyes. You can find more information on the Replacement webpage.

Is the Item Same or Similar?

Prior to replacing an item, and to gain the necessary information required for determining whether same or similar is affected, these questions should be considered:

  • Has there been a change in the beneficiary's medical condition that supports the need for a same or similar type of item?
  • Has the original item been lost, stolen, or irreparably damaged?
    • Answering these questions will help determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained
  • Has the beneficiary had a same or similar item?
    • If he/she has not had a same or similar item, bill claim without obtaining an ABN (no ABN necessary)
    • If he/she has had a same or similar item, determine if item has reached its RUL  
    • If RUL reached, bill claim without ABN (no ABN necessary)
    • If item has not reached RUL, obtain an ABN and bill claim with applicable modifier

Verification options include:

  1. Ask beneficiary
  2. Check via Noridian Interactive Voice Response (IVR)
  3. Access such information within Noridian Medicare Portal (NMP)

If there is any reason to believe that a beneficiary may have obtained a same or similar item outside of Jurisdiction A, check with the other jurisdictions (B, C, and D) as well.

Same or Similar Chart

The list is NOT all inclusive and that while every effort is made to keep it current, there may be relationships that might trigger a denial that are not listed.

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Item Item Type Same HCPCS Category Similar HCPCS Category
AFO/KAFO O&P L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4398, L4631  
Bed Side Rails DME E0305, E0310 Hospital Beds with Rails
E0250, E0251, E0328, E0255, E0256, E0260, E0261, E0329, E0265, E0266, E0301, E0302, E0303, E0304
Blood Glucose Monitors DME E0607, E2100, E2101 K0554
Continuous Glucose Monitors DME K0554 E0607, E2100, E2101, E2102
Canes and Crutches DME E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116  
Commodes DME E0163, E0164, E0165, E0166, E0168, E0169, E0170, E0171  
External Breast Prosthesis O&P L8015, L8020, L8030, L8031, L8032, L8035, L8039  
Functional Electrical Stimulator DME E0764, E0770 E0720, E0730, A4595
Heat Lamps DME E0200, E0205  
Heat Pads DME E0210, E0215, E0217, E0220, E0221, E0225, E0236, E0238, E0239  
High Frequency Chest Wall Oscillation Devices DME E0483 E0480, E0482
Hospital Beds DME E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302, E0303, E0304, E0328, E0329  
Humidifiers
Note: When used with a positive airway pressure (PAP) device
DME E0561, E0562  
Infusion Pumps DME E0779, E0780, E0781, E0791  
Knee Orthoses O&P L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1850, L1851, L1852, L1860  
Manual Wheelchairs DME E1031, E1037, E1038, E1039, E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009 Canes and Crutches
E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116
Walkers
E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149
Mechanical In-exsufflation Devices DME E0482 E0480, E0483
Nebulizers and Compressors DME E0565, E0570, E0571, E0572, E0574, E0575, E0580, E0585  
NEMS DME A4595 E0720, E0730, E0764, E0770
Oxygen Contents (Portable) DME E0443, E0444  
Oxygen Contents (Stationary) DME E0441, E0442  
Oxygen, Portable Equipment DME E0430, E0431, E0433, E0434, E0435, E1392, K0738  
Oxygen, Stationary Equipment DME E0424, E0425, E0439, E0440, E1353, E1390, E1391, E1405, E1406  
Parenteral Pumps DME B9004, B9006  
Patient Lifts DME E0630, E0635, E0636, E0639, E0640  
Patient Lifts DME E1035, E1036 Canes and Crutches
E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118
Walkers
E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149
Patient Lifts
E0630, E0635, E0636, E0639, E0640
Percussor DME E0480 E0482, E0483
Pneumatic Appliances-Arm DME A4600, E0655, E0665, E0668, E0672  
Pneumatic Appliances-Leg DME A4600, E0660, E0666, E0667, E0669, E0671, E0673  
Pneumatic Compressors DME E0650, E0651, E0652, E0676  
Pneumatic Compressor Leg Appliances DME E0660, E0666, E0667, E0669, E0670, E0671, E0673, E0676  
Pneumatic Compressors Arm Appliances DME E0655, E0665, E0668, E0672, E0676  
Pneumatic Compressors Trunk Appliances DME E0656, E0657, E0670, E0676  
Power Wheelchairs DME E1035, E1036, E1230, K0013, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898 Manual Wheelchairs
E1031, E1037, E1038, E1039, E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1239, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0009
Walkers
E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149
Canes and Crutches
E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118
Pressure Reducing Support Surfaces DME E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0193, E0194, E0196, E0197, E0198, E0199, E0277, E0371, E0372, E0373  
Respiratory Assist Devices DME E0450, E0454, E0460, E0461, E0463, E0464, E0465, E0466, E0470, E0471, E0472, E0601  
Seat Lift Mechanisms DME E0627, E0628, E0629  
Speech Generating Devices DME E2500, E2502, E2504, E2506, E2508, E2510, E2511  
Spinal Orthoses - Lumbar Sacral Orthoses O&P L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651  
Stimulators DME E0747, E0760  
Therapeutic Shoes for Persons with Diabetes O&P A5500, A5501  
Traction Frames DME E0840, E0850, E0855, E0856, E0860, E0947, E0849  
Transcutaneous, Electrical Nerve Stimulators (TENS) DME E0720, E0730 E0764, E0770, A4595
Trapeze Bars DME E0910, E0911, E0912, E0940  
Ventilators DME E0465, E0466, E0467  
Walkers DME E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149 Canes and Crutches
E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118
Wheelchair Back Cushions DME E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2620, E2621  
Wheelchair Seat Cushions DME E2601, E2602, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2610, E2622, E2623, E2624, E2625, K0734, K0735, K0736, K0737  

 

Last Updated Tue, 26 Jul 2022 19:32:51 +0000