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

  1. Durable medical equipment (DME)
  2. Prosthetic devices (artificial legs, arms, and eyes, including replacement prostheses)
  3. Leg, arm, back and neck braces (orthoses)
  4. Surgical dressings
  5. Immunosuppressive drugs
  6. Intravenous Immune Globulin
  7. Lymphedema Compression Treatment Items
  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. 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)




Last Updated Feb 27 , 2024