Link to Table A: Durable Medical Equipment (DME), Prosthetics and Orthotics HCPCS Codes that Require Precertification
The following items in Table B that do not require precertification (even if allowance is more than $500):
| HCPCS | Description |
|---|---|
| A4557 | Lead wires, (e.g., apnea monitor), per pair |
| A4595 | Electrical stimulator supplies, 2 leads, per month, (e.g., TENS, NMES) |
| A6550 | Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories |
| A7000 | Canister, disposable, used with suction pump, each |
| E0250 | Hospital bed, fixed height, with any type of side rails, with mattress (effective 02/01/2021) |
| E0251 | Hospital bed, fixed height, with any type side rails, without mattress (effective 02/01/2021) |
| E0255 | Hospital bed, variable height, hi-lo, with any type side rails, with mattress (effective 02/01/2021) |
| E0256 | Hospital bed, variable height, hi-lo, with any type side rails, without mattress (effective 02/01/2021) |
| E0260 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (effective 02/01/2021) |
| E0261 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress (effective 02/01/2021) |
| E0290 | Hospital bed, fixed height, without side rails, with mattress (effective 02/01/2021) |
| E0291 | Hospital bed, fixed height, without side rails, without mattress (effective 02/01/2021) |
| E0292 | Hospital bed, variable height, hi-lo, without side rails, with mattress (effective 02/01/2021) |
| E0293 | Hospital bed, variable height, hi-lo, without side rails, without mattress (effective 02/01/2021) |
| E0294 | Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress (effective 02/01/2021) |
| E0295 | Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress (effective 02/01/2021) |
| E0301 | Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress (effective 02/01/2021) |
| E0302 | Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress (effective 02/01/2021) |
| E0303 | Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds but less than or equal to 600 pounds, with any type side rails, with mattress (effective 02/01/2021) |
| E0304 | Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress (effective 02/01/2021) |
| E0601 | Continuous positive airway pressure (CPAP) device (effective 2/1/23) |
| E0720 | TENS, two lead, localized stimulation |
| E0730 | Transcutaneous electrical nerve stimulation device (TENS), four or more leads, for multiple nerve stimulation |
| E0731 | Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient’s skin by layers of fabric) |
| E2402 | Negative pressure wound therapy electrical pump, stationary or portable |
| V2623 | Prosthetic eye, plastic, custom (effective 02/01/2021) |
| V2624 | Polishing/resurfacing of ocular prosthesis (effective 02/01/2021) |
| V2625 | Enlargement of ocular prosthesis (effective 02/01/2021) |
| V2626 | Reduction of ocular prosthesis (effective 02/01/2021) |
| V2627 | Scleral cover shell (effective 02/01/2021) |
| V2628 | Fabrication and fitting of ocular conformer (effective 02/01/2021) |
| V2629 | Prosthetic eye, other type (effective 02/01/2021) |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|