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Noncovered Items

In order for an item to be covered by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC), it must fall within one of ten benefit categories. 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:

  1. Durable medical equipment (DME)
  2. Prosthetic devices
  3. Leg, arm, back and neck braces (orthoses) and artificial leg, arm and eyes, including replacement (prostheses)
  4. Home dialysis supplies and equipment
  5. Surgical dressings
  6. Immunosuppressive drugs
  7. Erythropoietin (EPO) for home dialysis patients
  8. Therapeutic shoes for diabetics
  9. Oral anticancer drugs
  10. Oral antiemetic drugs (replacement for intravenous antiemetics)

Some items may not meet the definition of a Medicare benefit or may be statutorily excluded. The items listed below will always be denied as non-covered. The Medicare National Coverage Determinations (NCD) Manual provides a list of items that are noncovered with the reason for denial. The following items 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
A4575
Topical hyperbaric oxygen chamber, disposable
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
A6530
Gradient compression stocking, below knee, 18-30 mmHg, each
A6533
Gradient compression stocking, thigh length, 18-30 mmHg, each
A6534
Gradient compression stocking, thigh length, 30-40 mmHg, each
A6535
Gradient compression stocking, thigh length, 40-50 mmHg, each
A6536
Gradient compression stocking, full length/chap style, 18-30 mmHg, each
A6537
Gradient compression stocking, full length/chap style, 30-40 mmHg, each
A6538
Gradient compression stocking, full length/chap style, 40-50 mmHg, each
A6540
Gradient compression stocking, waist length, 30-40 mmHg, each
A6541
Gradient compression stocking, waist length, 40-50 mmHg, each
A6542
Gradient compression stocking, custom made
A6543
Gradient compression stocking, lymphedema
A6544
Gradient compression stocking, garter belt
A6549
Gradient compression stocking, not otherwise specified
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
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
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
L7600
Prosthetic donning sleeve, any material, each
Q0144
Azithromycin dehydrate, oral, capsules/powder, 1 gram
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 Nov 11, 2016