Non-Covered Items

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Non-Covered Items

The following HCPCS codes will be denied as non-covered when they are submitted to the DME MAC.

These items either do not meet the requirements for a benefit category processed by the DME MAC

(technical denial) or are statutorily excluded for reasons other than lack of medical necessity. These

items may be covered under other provisions of the law (e.g., as part of institutional care in a hospital

or nursing facility, as an item incident to a physician’s service, etc.). However, in these circumstances,

the claim would not be submitted to the DME MAC and/or would be submitted using a different code.

A4210 Needle-free injection device, each

A4261 Cervical cap for contraceptive use

A4335 Disposable sheets and bags

A4554 Disposable underpads

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

A4554 Disposable underpads, all sizes, (e.g., chux’s)

A4565 Slings

A4575 Topical hyperbaric oxygen chamber, disposable

A4627 Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler

A4670 Automatic blood pressure monitor

A6000 Noncontact wound warming wound cover for use with the noncontact wound warming device

and warming card

A9190 Personal comfort item

A9270 Noncovered item or service

A9300 Exercise equipment

E0191 Heel or elbow protector, each

E0220 Hot water bottle

E0230 Cap or collar

E0231 Noncontact wound warming device

E0232 Warming card for use with the noncontact wound warming device and noncontact wound

warming wound cover

E0238 Nonelectric heat pad, moist

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

E0270 Hospital bed, institutional type includes: oscillating, circulating, and stryker frame with mattress

E0273 Bed board

E0274 Over-bed table

E0315 Bed accessories and boards or tables, any type

E0625 Patient lift, kartop, bathroom, or toilet

E0700 Safety equipment (e.g., belt, harness or vest)

E0746 Biofeedback therapy for the treatment of urinary incontinence

E1300 Whirlpool, nonportable (overtub type)

E1355 Stand rack

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 b17

J7300 Intrauterine copper contraceptive

J8499 Prescription drug, oral, nonchemotherapeutic, NOS

L3215 Orthopedic footwear, ladies shoes, oxford

L3216 Orthopedic footwear, ladies shoes, depth inlay

L3217 Orthopedic footwear, ladies shoes, hightop, depth inlay

L3219 Orthopedic footwear, mens shoes, oxford

L3221 Orthopedic footwear, mens shoes, depth inlay

L3222 Orthopedic footwear, mens shoes, hightop, depth inlay

Q0144 Azithromycin dihydrate, 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

V2760 Scratch resistant coating, per lens

V5008 Hearing screening

V5010 Assessment for hearing aid

V5011 Fitting/orientation/checking of hearing aid

V5014 Repair/modification of a hearing aid

V5020 Conformity evaluation

V5030 Hearing aids

V5299 Hearing devices

V5336 Repair/modification of augmentative communicative system or device (excludes adaptive

hearing aid)

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