Non-Covered Items

Noncovered Items

The following HCPCS codes will be denied as noncovered 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)