These items require an in-person, face-to-face interaction between the beneficiary and their treating physician prior to prescribing the item. This face-to-face requirement includes examinations conducted via the CMS-approved use of telehealth examinations. This face-to-face evaluation must specifically document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered. A dispensing order is not sufficient to provide these items. A 5EO must be received prior to delivery. Refer to the applicable LCD-related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section for information about these statutory requirements.

Documentation Types

• ACA Face-to-Face - A practitioner (MD, DO, DPM, PA, NP, CNS) has had a F2F examination with a beneficiary within the six (6) months prior to the written order for certain DME items.
• ACA 5EO - For some items to be covered by Medicare, a written order is required to be in the supplier's file prior to delivery of the specified item(s).

ACA Items

This list is subject to CMS annual review and may change as necessary.

HCPCS Code	Description
E0185	Gel or gel-like pressure mattress pad
E0188	Synthetic sheepskin pad
E0189	Lamb's wool sheepskin pad
E0194	Air fluidized bed
E0197	Air pressure pad for mattress standard length and width
E0198	Water pressure pad for mattress standard length and width
E0199	Dry pressure pad for mattress standard length and width
E0250	Hospital bed fixed height with any type side rails, mattress
E0251	Hospital bed fixed height with any type side tails without mattress
E0255	Hospital bed variable height with any type side rails with mattress
E0256	Hospital bed variable height with any type side rails without mattress
E0260	Hospital bed semi-electric (Head and foot adjustment) with any type side rails with mattress
E0261	Hospital bed semi-electric (head and foot adjustment ) with any type side rails without mattress
E0265	Hospital bed total electric (head, foot and height adjustments) with any type side rails with mattress
E0266	Hospital bed total electric (head, foot and height adjustments) with any type side rails without mattress
E0290	Hospital bed fixed height without rails with mattress
E0291	Hospital bed fixed height without rails without mattress
E0292	Hospital bed variable height without rail without mattress
E0293	Hospital bed variable height without rail with mattress
E0294	Hospital bed semi-electric (head and foot adjustments) without rail with mattress
E0295	Hospital bed semi-electric (head and foot adjustments) without rail without mattress
E0296	Hospital bed total electric (head, foot and height adjustments) without rail with mattress
E0297	Hospital bed total electric (head, foot and height adjustments) without rail without mattress
E0300	Pediatric crib, hospital grade, fully enclosed
E0301	Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, without mattress
E0302	Hospital bed, Heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of tail, without mattress
E0303	Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, with mattress
E0304	Hospital bed heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of rail, with mattress
E0424	Stationary compressed gas Oxygen System rental: includes contents, regulator, nebulizer, cannula or mask and tubing
E0431	Portable gaseous oxygen system rental includes portable container, regulator, flowmeter, humidifier, cannula or mask, an tubing
E0433	Portable liquid oxygen system
E0434	Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, content gauge, cannula or mask, and tubing
E0439	Stationary liquid oxygen system rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0441	Oxygen contents, gaseous (1 months supply)
E0442	Oxygen contents, liquid (1 months supply)
E0443	Portable Oxygen contents, gas (1 months supply)
E0444	Portable oxygen contents, liquid (1 months supply)
E0450	Volume control ventilator without pressure support used with invasive interface
E0460	Negative pressure ventilator portable or stationary
E0461	Volume control ventilator without pressure support node for a noninvasive interface
E0462	Rocking bed with or without side rail
E0463	Pressure support ventilator with volume control mode used for invasive surfaces
E0464	Pressure support vent with volume control mode used for noninvasive surfaces
E0470	Respiratory Assist Device, bi-level pressure capability, without backup rate used non-invasive interface
E0471	Respiratory Assist Device, bi-level pressure capability, with backup rate for non-invasive interface
E0472	Respiratory Assist Device, bi-level pressure capability, with backup rate for invasive interface
E0480	Percussor electric/pneumatic home model
E0482	Cough stimulating device, alternating positive and negative airway pressure
E0483	High Frequency chest wall oscillation air pulse generator system
E0484	Oscillatory positive expiratory device, non-electric
E0570	Nebulizer with compressor
E0575	Nebulizer, ultrasonic, large volume
E0580	Nebulizer, durable, glass or autoclavable plastic, bottle type for use with regulator or flowmeter
E0585	Nebulizer with compressor & heater
E0601	Continuous airway pressure device
E0607	Home blood glucose monitor
E0627	Seat lift mechanism incorporated lift-chair
E0628	Separate Seat lift mechanism for patient owned furniture electric
E0629	Separate seat lift mechanism for patient owned furniture non-electric
E0636	Multi positional patient support system, with integrated lift, patient accessible controls
E0650	Pneumatic compressor non-segmental home mode
E0651	Pneumatic compressor segmental home model without calibrated gradient pressure
E0652	Pneumatic compressor segmental home model with calibrated gradient pressure
E0655	Non-segmental pneumatic appliance for use with pneumatic compressor on half arm
E0656	Non-segmental pneumatic appliance for use with pneumatic compressor on trunk
E0657	Non-segmental pneumatic appliance for use with pneumatic compressor on chest
E0660	Non-segmental pneumatic appliance for use with pneumatic compressor on full leg
E0665	Non-segmental pneumatic appliance for use with pneumatic compressor on full arm
E0666	Non-segmental pneumatic appliance for use with pneumatic compressor on half leg
E0667	Segmental pneumatic appliance for use with pneumatic compressor on full leg
E0668	Segmental pneumatic appliance for use with pneumatic compressor on full arm
E0669	Segmental pneumatic appliance for use with pneumatic compressor on half leg
E0671	Segmental gradient pressure pneumatic appliance full leg
E0672	Segmental gradient pressure pneumatic appliance full arm
E0673	Segmental gradient pressure pneumatic appliance half leg
E0675	Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency
E0692	Ultraviolet light therapy system panel treatment 4 foot panel
E0693	Ultraviolet light therapy system panel treatment 6 foot panel
E0694	Ultraviolet multidirectional light therapy system in 6 foot cabinet
E0720	Transcutaneous electrical nerve stimulation, two lead, local stimulation
E0730	Transcutaneous electrical nerve stimulation, four or more leads, for multiple nerve stimulation
E0731	Form fitting conductive garment for delivery of TENS or NMES
E0740	Incontinence treatment system, Pelvic floor stimulator, monitor, sensor and/or trainer
E0744	Neuromuscular stimulator for scoliosis
E0745	Neuromuscular stimulator electric shock unit
E0747	Osteogenesis stimulator, electrical, non-invasive, other than spine application
E0748	Osteogenesis stimulator, electrical, non-invasive, spinal application
E0749	Osteogenesis stimulator, electrical, surgically implanted
E0760	Osteogenesis stimulator, low intensity ultrasound, non-invasive
E0762	Transcutaneous electrical joint stimulation system including all accessories
E0764	Functional neuromuscular stimulator, transcutaneous stimulations of muscles of ambulation with computer controls
E0765	FDA approved nerve stimulator for treatment of nausea & vomiting
E0782	Infusion pumps, implantable, non-programmable
E0783	Infusion pump, implantable, programmable
E0784	External ambulatory infusion pump
E0786	Implantable programmable infusion pump, replacement
E0840	Tract frame attach to headboard, cervical traction
E0849	Traction equipment cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible
E0850	Traction stand, free standing, cervical traction
E0855	Cervical traction equipment not requiring addition stand or frame
E0856	Cervical traction device, cervical collar with inflatable air bladder
E0958	Manual wheelchair accessory, one-arm drive attachment
E0959	Manual wheelchair accessory, adapter for amputee
E0960	Manual wheelchair accessory, shoulder harness/strap
E0961	Manual wheelchair accessory wheel lock brake extension handle
E0966	Manual wheelchair accessory, headrest extension
E0967	Manual wheelchair accessory, hand rim with projections
E0968	Commode sear, wheelchair
E0969	Narrowing device wheelchair
E0971	Manual wheelchair accessory anti-tipping device
E0973	Manual wheelchair accessory, adjustable height, detachable armrest
E0974	Manual wheelchair accessory anti-rollback device
E0978	Manual wheelchair accessory positioning belt/safety belt/pelvic strap
E0980	Manual wheelchair accessory safety vest
E0981	Manual wheelchair accessory seat upholstery, replacement only
E0982	Manual wheelchair accessory, back upholstery, replacement only
E0983	Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, joystick control
E0984	Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, tiller control
E0985	Wheelchair accessory, seat lift mechanism
E0986	Manual wheelchair accessory, push activated power assist
E0990	Manual wheelchair accessory, elevating leg rest
E0992	Manual wheelchair accessory, solid seat insert
E0994	Arm rest
E1014	Reclining back, addition to pediatric size wheelchair
E1015	Shock absorber for manual wheelchair
E1020	Residual limb support system for wheelchair
E1028	Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
E1029	Wheelchair accessory, ventilator tray
E1030	Wheelchair accessory, ventilator tray, gimbaled
E1031	Rollabout chair, any and all types with castors 5" or greater
E1035	Multi-positional patient transfer system with integrated seat operated by care giver
E1036	Patient transfer system
E1037	Transport chair, pediatric size
E1038	Transport chair, adult size up to 300lb
E1039	Transport chair, adult size heavy duty >300lb
E1161	Manual adult size wheelchair includes tilt in space
E1227	Special height arm for wheelchair
E1228	Special back height for wheelchair
E1232	Wheelchair, pediatric size, tilt-in-space, folding, adjustable with seating system
E1233	Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system
E1234	Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system
E1235	Wheelchair, pediatric size, rigid, adjustable, with seating system
E1236	Wheelchair, pediatric size, folding, adjustable, with seating system
E1237	Wheelchair, pediatric size, rigid, adjustable, without searing system
E1238	Wheelchair, pediatric size, folding, adjustable, without searing system
E1296	Special sized wheelchair seat height
E1297	Special sized wheelchair seat depth by upholstery
E1298	Special sized wheelchair seat depth and/or width by construction
E1310	Whirlpool non-portable
E2502	Speech generating devices prerecord messages between 8 and 20 minutes
E2506	Speech generating devices prerecord messages over 40 minutes
E2508	Speech generating devices message through spelling, manual type
E2510	Speech generating devices synthesized with multiple message methods
E2227	Rigid pediatric wheelchair adjustable
K0001	Standard wheelchair
K0002	Standard hemi (low seat) wheelchair
K0003	Light weight wheelchair
K0004	High strength ltwt wheelchair
K0005	Ultra lightweight wheelchair
K0006	Heavy duty wheelchair
K0007	Extra heavy duty wheelchair
K0009	Other manual wheelchair/base
K0606	AED garment with electronic analysis
K0730	Controlled dose inhalation drug delivery system

 

Resources

• ACA Face-to-Face Requirements and CERT Enforcement
• CMS Face-to-Face Encounter Requirement for Certain Durable Medical Equipment
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5
• CMS Medicare Learning Network (MLN) Matters (MM)8304