Durable Medical Equipment HCPCS Codes

Partial HandLPartial hand, thumb remainingYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPartial hand, little and/or ring finger remainingYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPartial hand, no finger remainingYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTranscarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)Yes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Wrist DisarticulationLWrist disarticulation, molded socket, flexible elbow hinges, triceps padYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LWrist disarticulation molded socket with expandable interface, flexible elbow hinges, triceps padYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Below ElbowLBelow elbow, molded socket, flexible elbow hinge, triceps padYes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.LBelow elbow, molded socket, (Muenster or Northwestern suspension types)Yes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LBelow elbow, molded double wall split socket, step-up hinges, half cuffYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LBelow elbow, molded double wall split socket, stump activated locking hinge, half cuffYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Elbow DisarticulationLElbow disarticulation, molded socket, outside locking hinge, forearmYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElbow disarticulation, molded socket with expandable interface, outside locking hinges, forearmYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Above ElbowEDynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface materialYes2/Y*Code is subject to the DME UPLLAbove elbow molded double wall socket, internal locking elbow, forearmYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Shoulder DisarticulationLShoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearmYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LShoulder disarticulation, passive restoration (complete prosthesis)Yes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LShoulder disarticulation, passive restoration (shoulder cap only)Yes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Interscapular ThoracicLInterscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearmYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LInterscapular thoracic, passive restoration (complete prosthesis)Yes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LInterscapular thoracic, passive restoration (shoulder cap only)Yes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Immediate and Early Post-Surgical ProceduresLImmediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one (1) cast change, wrist disarticulation or below elbowYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LImmediate post-surgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one (1) cast change, elbow disarticulation or above elbowYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LImmediate post-surgical or early fitting, application of initial rigid dressing including fitting, alignment and suspension of components, and one (1) cast change, shoulder disarticulation or interscapular thoracicYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LImmediate post-surgical or early fitting, each additional cast change and realignmentNo  LImmediate post-surgical or early fitting, application of rigid dressing onlyNo  Endoskeletal: Below ElbowLBelow elbow, molded socket, endoskeletal system, including soft prosthetic tissue shapingYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Endoskeletal: Elbow DisarticulationLElbow disarticulation, molded socket, endoskeletal system including soft prosthetic tissue shapingYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Endoskeletal: Above ElbowLAbove elbow, molded socket, endoskeletal system including soft prosthetic tissue shapingYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Endoskeletal: Shoulder DisarticulationLShoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shapingYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Endoskeletal: Interscapular ThoracicLInterscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shapingYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPreparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, molded to patient modelYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPreparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, direct formedYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPreparatory, wrist disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient modelYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPreparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, direct formedYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPreparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient modelYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPreparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, direct formedYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Additions: Upper Limb
The following procedures/modifications/components may be added to other base procedures. The items in this section should reflect the additional complexity of each modification procedure, in addition to the base procedure, at the time of the original order.LUpper extremity additions, polycentric hinge, pairNo  LUpper extremity additions, single pivot hinge, pairNo  LUpper extremity additions, flexible metal hinge, pairNo  LAddition to upper extremity prosthesis, external powered, additional switch, any typeNo  LUpper extremity addition, disconnect locking wrist unitNo  LUpper extremity addition, additional disconnect insert for locking wrist unit, eachNo  LUpper extremity addition, flexion-friction wrist unit, with or without frictionNo  LUpper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal deviceYes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.LUpper extremity addition, spring assisted rotational wrist unit with latch releaseNo  LUpper extremity addition, flexion/extension and rotation wrist unitNo  LUpper extremity addition, rotation wrist unit with cable lockNo  LUpper extremity addition, quick disconnect hook adapter, Otto Bock or equalNo  LUpper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equalNo  LUpper extremity addition, stainless steel, any wristNo  LUpper extremity addition, latex suspension sleeve, eachNo  LUpper extremity addition, life assist for elbowNo  LUpper extremity addition, nudge control elbow lockNo  LUpper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbowNo  LUpper extremity additions, shoulder abduction joint, pairNo  LUpper extremity addition, excursion amplifier, pulley typeNo  LUpper extremity addition, excursion amplifier, lever typeNo  LUpper extremity addition, shoulder flexion-abduction joint, eachNo  LUpper extremity addition, shoulder joint, multi-positional locking, flexion, adjustable abduction friction control, for use with body powered or external powered systemNo  LUpper extremity addition, shoulder lock mechanism, body powered actuatorNo  LUpper extremity addition, shoulder lock mechanism, external powered actuatorNo  LUpper extremity addition, shoulder universal joint, eachNo  LUpper extremity addition, standard control cable, extraNo  LUpper extremity addition, heavy duty control cableNo  LUpper extremity addition, Teflon, or equal, cable liningNo  LUpper extremity addition, hook to hand, cable adapterNo  LUpper extremity addition, harness, chest or shoulder, saddle typeNo  LUpper extremity addition, harness, (e.g. figure of eight type), single cable designNo  LUpper extremity addition, harness, (e.g. figure of eight type), dual cable designNo  LUpper extremity addition, harness, triple control, simultaneous operation of terminal device and elbowNo  LUpper extremity addition, test socket, wrist disarticulation or below elbowNo  LUpper extremity addition, test socket, elbow disarticulation or above elbowNo  LUpper extremity addition, test socket, shoulder disarticulation or interscapular thoracicNo  LUpper extremity addition, suction socketNo  LUpper extremity addition, frame type socket, below elbow or wrist disarticulationNo  LUpper extremity addition, frame type socket, above elbow or elbow disarticulationNo  LUpper extremity addition, frame type socket, shoulder disarticulationNo  LUpper extremity addition, frame type socket, interscapular-thoracicNo  LUpper extremity addition, removable insert, eachNo  LUpper extremity addition, silicone gel insert or equal, eachNo  LUpper extremity addition, locking elbow, forearm counterbalanceYes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.LAddition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanismNo  LAddition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanismNo  LAddition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L or L)Yes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.LAddition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L or L)Yes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.LAddition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insertNo  Terminal DevicesLTerminal device, passive hand/mitt, any material, any sizeNo  LTerminal device, sport/recreation/work attachment, any material, any sizeYes*2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, LTerminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlinedNo  LTerminal device, hook, mechanical, voluntary closing, any material, any sized, lined or unlinedYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTerminal device, hand, mechanical, voluntary opening, any material, any sizeYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTerminal device, hand, mechanical, voluntary closing, any material, any sizeYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTerminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatricNo  LTerminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatricYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTerminal device, hand, mechanical, voluntary opening, any material, any size, pediatricYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTerminal device, hand, mechanical, voluntary closing, any material, any size, pediatricYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTerminal device, multiple articulating digit, includes motor(s), initial issue or replacementYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTerminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlinedYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LTerminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlinedYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LAddition to terminal device, modifier wrist unitNo  LAddition to terminal device, precision pinch deviceNo  LElectric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)Yes*2/5Y*Effective April 1, LAutomatic grasp feature, addition to upper limb electric prosthetic terminal deviceYes2/5Y*Effective April 1, , a prior authorization is required.LMicroprocessor control feature, addition to upper limb prosthetic terminal deviceYes2/5Y*Effective April 1, , a prior authorization is required.Replacement SocketsLReplacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external powerYes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.LReplacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external powerYes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.LReplacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external powerYes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.Gloves for Above HandsLAddition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustmentYes  LAddition to upper extremity prosthesis, glove for terminal device, any material, custom fabricatedYes*2/5Y*Effective April 1, Hand RestorationLHand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one (1) finger remainingYes*2/5Y*Effective April 1, LHand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remainingYes*2/5Y*Effective April 1, LHand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remainingYes*2/5Y*Effective April 1, LHand restoration (shading and measurements included), replacement glove for aboveYes*2/5Y*Effective April 1, External Power Base DevicesLWrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LWrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LBelow elbow, external power, self- suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LBelow elbow, external power, self- suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LAbove elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LAbove elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one charger, myoelectronic control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LShoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LShoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LInterscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two (2) batteries and one (1) charger, switch control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LInterscapular thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two (2) batteries and one (1) charger, myoelectronic control of terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectric hand, switch or myoelectric, controlled, adultYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectric hand, switch or myoelectric, controlled, pediatricYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectric hook, switch or myoelectric controlled, adultYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LPrehensile actuator, switch controlledYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectronic hook, switch or myoelectric controlled, pediatricYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Electronic ElbowLElectronic elbow, Hosmer or equal, switch controlledYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectronic elbow, microprocessor sequential control of elbow and terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectronic elbow, microprocessor simultaneous control of elbow and terminal deviceYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectronic elbow, adolescent, Variety Village or equal, switch controlledYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectronic elbow, child, Variety Village or equal, switch controlledYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectronic elbow, adolescent, Variety Village or equal, myoelectronically controlledYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.LElectronic elbow, child, Variety Village or equal, myoelectronically controlledYes2/5YOne (1) per right and left side, every five (5) years.
*Effective April 1, , a prior authorization is required.Battery ComponentsLSix (6) volt battery, eachYes2/Y*Effective April 1, , a prior authorization is required.LBattery charger, six (6) volt, eachYes2/5Y*Effective April 1, , a prior authorization is required.L-volt battery, eachYes2/Y*Effective April 1, , a prior authorization is required.LBattery charger, 12 volt, eachYes2/5Y*Effective April 1, , a prior authorization is required.LLithium ion battery, replacementYes2/Y*Effective April 1, , a prior authorization is required.LLithium ion battery charger, replacement onlyYes2/5Y*Effective April 1, , a prior authorization is required.Addition to Upper Extremity ProsthesisLAddition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)No  LAddition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)No  LAddition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)No  LAddition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic materialNo  LAddition to upper extremity prosthesis, above elbow disarticulation, acrylic materialNo  LAddition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic materialNo  LUpper extremity prosthesis, NOSYes *Effective April 1, , a prior authorization is required.RepairsLRepair of prosthetic device, repair or replace minor partsNo  LRepair prosthetic device, labor component, per 15 minutesNo  ProsthesesLBreast prosthesis, mastectomy braNo  LBreast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any typeNo  LBreast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any typeNo  LBreast prosthesis, mastectomy sleeveNo  LExternal breast prosthesis garment, with mastectomy form, post-mastectomyNo  LBreast prosthesis, mastectomy formNo  LBreast prosthesis, silicone or equal, without integral adhesiveYes2/Y*Effective April 1, LBreast prosthesis, silicone or equal, with integral adhesiveYes2/5Y*Effective April 1, LNipple prosthesis, reusable, any type, eachYes2/5Y*Effective April 1, LCustom breast prosthesis, post mastectomy, molded to patient modelYes2/5YOne (1) per right and left side, every five (5) years. *Effective April 1, , a prior authorization is required.LBreast prosthesis, NOSYes2/5Y*Effective April 1, LNasal prosthesis, provided by a non- physicianYes1/5Y*Effective April 1, LMidfacial prosthesis, provided by a non- physicianYes1/5Y*Effective April 1, LOrbital prosthesis, provided by a non- physicianYes2/5Y*Effective April 1, LUpper facial prosthesis, provided by a non-physicianYes1/5Y*Effective April 1, LHemi-facial prosthesis, provided by a non-physicianYes1/5Y*Effective April 1, LAuricular prosthesis, provided by a non- physicianYes2/5Y*Effective April 1, LPartial facial prosthesis, provided by a non-physicianYes1/5Y*Effective April 1, LNasal septal prosthesis, provided by a non-physicianYes*1/5Y*Effective April 1, LUnspecified maxillofacial prosthesis, by report, provided by a non-physicianYes  LRepair or modification of maxillofacial prosthesis, labor component, 15-minute increments, provided by a non-physicianYes  LUnlisted procedure for miscellaneous prosthetic servicesYes  LImplantable breast prosthesis, silicone or equalNone  LAqueous shuntNone  TrussesLTruss, single with standard padNo  LTruss, double with standard padsNo  LTruss, addition to standard pads, water padNo  LTruss, addition to standard pads, scrotal padNo  Prosthetic SocksLProsthetic donning sleeve, any material, eachNo  LProsthetic sheath, below knee, eachNo  LProsthetic sheath, above knee, eachNo  LProsthetic sheath upper limb eachNo  LProsthetic sheath/sock, including a gel cushion layer, below knee or above knee, eachNo  LProsthetic sock, multiple ply, below knee, eachNo  LProsthetic sock, multiple ply, above knee, eachNo  LProsthetic sock, multiple ply, upper limb, eachNo  LProsthetic shrinker, below knee, eachNo  LProsthetic shrinker, above knee, eachNo  LProsthetic shrinker, upper limb, eachNo  LProsthetic sock, single ply, fitting, below knee, eachNo  LProsthetic sock, single ply, fitting, above knee, eachNo  LProsthetic sock, single ply, fitting, upper limb, eachNo  Prosthetic ImplantsIntegumentary SystemLArtificial larynx, any typeYes1/5Y*Effective April 1, , a prior authorization is required.LTracheostomy speaking valveNo  LArtificial larynx replacement battery/accessory, any typeYes*1/Y*Effective April 1, LTracheo-esophageal voice prosthesis, patient inserted, any type, eachYes*1/Y*Effective April 1, LTracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any typeYes*1/Y*Effective April 1, LVoice amplifierYes  LInsert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, eachNo  LGelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10No  LCleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, eachNo  LTracheoesophageal puncture dilator, replacement only, eachNo  LGelatin capsule application device for use with tracheoesophageal voice prosthesis, eachNo31/M Hand and FootLMetacarpophalangeal joint implantNone  LMetacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel of cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)None  LMetatarsal joint implantNone  LHallux implantNone  LInterphalangeal joint spacer, silicone or equal, eachNone  LInterphalangeal finger joint replacement, 2 or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any sizeNone  Miscellaneous ImplantsLProsthetic Implant, not otherwise specifiedNone  Head: Skull, Facial Bones and Temporomandibular JointLOcular implantYes*2/5Y*Effective April 1, Alternative and Augmentative Communication Devices (AACDs)ALithium ion battery for non-prosthetic use, replacementYes  E-AVTablet computer for use as a communication deviceYes Device must be under full manufacturer warranty at the time of delivery to the member.
If TPL requires a different code, note the other code in the comments. EOB must be attached.
Required: F2FECommunication board, non-electronic augmentative or alternative communication deviceYes  ESpeech generating device, digitalized speech, using pre-recorded messages, less than or equal to 8 minutes recording timeYes *Code is subject to the DME UPLESpeech generating device, digitalized speech, using pre-recorded messages, greater than 8 minutes but less than or equal to 20 minutes recording timeYes Required: F2F
*Code is subject to the DME UPLESpeech generating device, digitalized speech, using pre-recorded messages, greater than 20 minutes but less than or equal to 40 minutes recording timeYes Required: F2FESpeech generating device, digitalized speech, using pre-recorded messages, greater than 40 minutes recording timeYes Required: F2F
*Code is subject to the DME UPLESpeech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the deviceYes Required: F2F
*Code is subject to the DME UPLESpeech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device accessYes Required: F2F
*Code is subject to the DME UPLESpeech generating software program, for personal computer or personal digital assistantYes  EAccessory for speech generating device, mounting systemYes  EAccessory for speech generating device, not otherwise classifiedYes  ESpeech volume modulation system, any type, including all components and accessoriesYes Code opened 01-01-.LOrthotic and prosthetic supply, accessory, and/or service component of another HCPCS L codeYes