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Try CasePilot| Short Descr | Ther cgm supply allowance | Coverage | Special coverage instructions apply | Pricing Indicator(s) | 34 – Supplies And Surgical Dressings - DME supplies (price subject to floors and ceilings) | MPI | A – Not applicable, as HCPCS priced under one methodology | Processing Note | CMS-1682-R. | BETOS | D1E – Other DME | TOS Code(s) | 9 – Other medical items or services | Added Date | 7/1/2017 | Termination Date | 12/31/2022 | APC Status Indicator | Non-Implantable Durable Medical Equipment | MUE | Not applicable/unspecified. | MUE | Not applicable/unspecified. | OTS Orthotic | No | CCS Clinical Classification | 243 - DME and supplies |
| NU | New equipment | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CG | Policy criteria applied | K4 | Lower extremity prosthesis functional level 4 - has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or energy levels, typical of the prosthetic demands of the child, active adult, or athlete. | KF | Item designated by fda as class iii device | KX | Requirements specified in the medical policy have been met |
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