Claims submitted with the procedure codes listed in this document must be accompanied by clinical information that supports the services rendered. Some services may require medical review because of one or more of the following reasons:
- The item is considered new technology.
- There is limited effectiveness when the item is used for certain medical conditions.
- The item itself is being used for an indication that is not FDA-approved.
- The item is not performed very often.
- There is a potential for the item to be used inappropriately or for other reasons related to medical necessity.
In some cases, practitioners may request an HMSA review prior to the item being ordered for benefit predetermination. Please refer to Benefit Information for more details on this process.
| Code | Description | Documentation Required |
|---|---|---|
| 0446T | Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training | Clinical Notes |
| 0447T | Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision | Clinical Notes |
| 0448T | Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation | Clinical Notes |
| A4459 | Anual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type | Clinical notes |
| A4479 | Electronic transanal irrigation system, includes electronic pump, water reservoir, tubing, and accessories, without catheter, any type | Clinical Notes |
| A8005 | Powered, cable driven grip assist glove, hand, finger, includes microprocessor, pressure sensors, all components and accessories, custom fitted | Diagnostic/Imaging Report |
| A7020 | Interface for cough stimulating device, includes all components, replacement only | Service will be processed based on the determination of the initial equipment billed under E0482. |
| A9285 | Inversion/eversion correction device | Clinical notes |
| E0467 | Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions | Clinical notes |
| E0468 | Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components and supplies for all functions | Clinical Notes |
| E0683 | Nonpneumatic, nonsequential, peristaltic wave compression pump | Operative Report |
| E0737 | Transcutaneous tibial nerve stimulator, controlled by phone application | Clinical notes |
| E0738 | Upper extremity rehabilitation system providing active assistance to facilitate muscle re-education, include microprocessor, all components and accessories | Consult Report |
| E0739 | Rehab system with interactive interface providing active assistance in rehabilitation therapy, includes all components and accessories, motors, microprocessors, sensors | Consult Report |
| E0743 | External lower extremity nerve stimulator for restless legs syndrome, each | Diagnostic/Imaging Report |
| E0749 | Osteogenesis stimulator, electrical, surgically implanted | Clinical notesResults of prior tests related to this condition |
| E0767 | Intrabuccal, systemic delivery of amplitude-modulated, radiofrequency electromagnetic field device, for cancer treatment, includes all accessories | Clinical Notes |
| E1352 | Oxygen accessory, flow regulator capable of positive inspiratory pressure | Clinical notes |
| E1629 | Tablo Hemodialysis System For The Billable Dialysis Service | Clinical notes |
| E2120 | Pulse generator system for tympanic treatment of inner ear endolymphatic fluid | Clinical notes |
| E2298 | Complex rehabilitative power wheelchair accessory, power seat elevation system, any type | Clinical notes |
| K1021 | Exsufflation belt, includes all supplies and accessories | Clinical notes |
| K1022 | Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type | Clinical notes |
| K1027 | Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment | Clinical notes |
| L1320 | Thoracic, pectus carinatum orthosis, sternal compression, rigid circumferential frame with anterior and posterior rigid pads, custom fabricated | Clinical notes |
| L2861 | Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabrication orthotics, only, each | Clinical notes |
| L3891 | Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each | Clinical notes |
| L5783 | Thoracic, pectus carinatum orthosis, sternal compression, rigid circumferential frame with anterior and posterior rigid pads, custom fabricated Clinical Notes L5783 Addition to lower extremity, user adjustable, mechanical, residual limb volume management system | Clinical notes |
| L5841 | Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control | Clinical notes |
| L5926 | Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type | Clinical notes |
| L5961 | Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control | Clinical notes |
| L6026 | Transcarpal/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) | Clinical notes |
| L7406 | Addition to upper extremity, user adjustable, mechanical, residual limb volume management system | Diagnostic/Imaging Report, Clinical Notes, and Consult Report are highly recommended. |
| L8627 | Cochlear implant, external speech processor, component, replacement | Clinical notes |
| L8628 | Cochlear implant, external controller component, replacement | Clinical notes |
| L8629 | Transmitting coil and cable, integrated, for use with cochlear implant device, replacement | Clinical notes |
| L8692 | Auditory Osseointegrated device, external sound processor, used with osseointegration, body worn, includes headband, or other means of external attachment | Clinical notes |
| L8693 | Auditory osseointegrated device abutement, any length, replacement only | Clinical notes |
| L8696 | Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation device, replacement, each | Clinical notes |
| L8720 | External lower extremity sensory prosthesis, cutaneous stimulation of mechanoreceptors proximal to the ankle, per leg | Clinical Notes |
| L8721 | Receptor sole for use with L8720, replacement, each | Clinical Notes |
| Q0478 | Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type | Clinical notes |
| Q0479 | Power module for use with electric or electric/pneumatic ventricular assist device, replacement only | Clinical notes |
| S1030 | Continuous noninvasive glucose monitoring device, purchase | Clinical notes |
| S1031 | Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor | Clinical notes |
| S2118 | Metal-on-metal total hip resurfacing with an FDA-approved device system, including acetabular and femoral components | Operative report
History and physical |
| S2270 | Insertion of vaginal cylinder for application of radiation source or clinical brachytherapy (report separately in addition to radiation source delivery) | Radiation oncology report
Consultation report |
Additional Resources
- Durable Medical Equipment Items Requiring and Not Requiring Certificate of Medical Necessity (CMN) or DME Information Form (DIF)
- Durable Medical Equipment, Prosthetics and Orthotics
In addition, HMSA may require submission of clinical records before or after payment of claims for the purpose of investigating potential fraudulent, abusive or other inappropriate billing practices, but only as long as there is a reasonable basis for believing such investigation is warranted.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |