Staywell Health Plan Durable Medical Equipment, Medical Supplies, Prostheses, and Orthoses Coverage and Billing Guide – Long Term Care
Staywell health plan provide coverage for medically necessary durable medical equipment (DME) and medical supplies pursuant to the Statewide Medicaid Managed Care (SMMC) program. Medical equipment is used to manage and treat a condition, illness, or injury. DME is used over and over again and includes things like wheelchairs, braces, crutches, and other items. Medical supplies are used to treat and manage conditions, illnesses, or injuries. Medical supplies include things that are used and then thrown away, like bandages, gloves, and other items. Additional items, including personal toiletries and household items such as detergent, bleach, and paper towels, may be covered as medically necessary for long-term care/comprehensive members.
General Authorization DME and medical supplies may require authorization for Medicaid members prior to delivery. To verify authorization at the code level, please use Staywell’s online prior authorization validation process at: https://www.wellcare.com/Florida/Providers/Authorization-Lookup.
All DME and medical supplies require authorization for long-term care/comprehensive members.
Codes Not Listed/Priced on Medicaid Fee Schedule Covered procedure codes not listed on the Medicaid Fee Schedule, not priced on the Medicaid Fee Schedule, or not specifically referenced in the provider agreement are reimbursable. HCPCS: E0602, K0606 are reimbursed off the Medicare Fee Schedule. Unlisted or unpriced codes are customarily priced at a percentage of MSRP of the invoice provided or based on a negotiated Single Case Agreement (SCA).
Bundled Codes Bundled Codes are only for rentals. Bundled services are considered global to the applicable Medicaid Fee Schedule rental rate. If the service is being provided for owned equipment, the services are payable as stand- alone services.
Modifiers Certain procedure codes have modifiers that are used with the HCPCS procedure codes to more fully describe the procedure performed. Please see procedure code modifiers for additional information.
Rent-to-Purchase For rent-to-purchase equipment, Medicaid’s total reimbursement may not exceed a total of ten (10) monthly claims. The provider may not submit a claim for more than one unit of service within the same calendar
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
month. When the tenth and final payment is made for a specific rent-to-purchase item, the equipment becomes the personal property of the Medicaid recipient.
Rental -only items remain the property of the provider, regardless of the number of months the item is rented. Reimbursement fees for rental-only items include all necessary home visits, repair, and maintenance. Rental- only equipment may be purchased if medically necessary. A request must be submitted via prior authorization and a SCA obtained.
Customized Equipment/Brand Supplies Requests for customized equipment or specific brand supplies, such as wheelchairs, may be approved based on medical necessity. A request must be submitted via prior authorization and a SCA obtained.
Excess Limits and Coding Requests for variances to coding and service limits may be approved based on medical necessity. This includes items that may be billed under miscellaneous codes. Miscellaneous codes should only be used when a more appropriate code does not exist. (For example, the DME miscellaneous code E1399 is utilized for robotic arm). A request must be submitted via prior authorization and a SCA obtained.
Supplies/Maintenance/Repairs Unless otherwise stated, services also include supplies, repair, maintenance, and replacement of all covered, medically necessary rented or owned equipment that is not covered under the warranty period. This includes equipment that may have been purchased prior to enrollment with Staywell. Certain equipment might be eligible for replacement if purchased prior to enrollment (e.g., oxygen equipment). Covered Services and Codes
Ambulatory Aids An ambulatory aid is a medically necessary item that is required by a recipient with impaired ambulation. Ambulatory aids include canes, crutches, and walkers that are to be complete with tips, pads, and grips. Pediatric gait trainers may be reimbursed as an ambulating aid. Wheeled walkers with a seat and wheel locks may be reimbursed, when prescribed in lieu of a wheelchair.
Apnea Monitors An apnea monitor is a device used to detect the cessation of breathing in infants and adults who are at risk of respiratory failure and alert the parent or attendant to the condition.
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Augmentative and Alternative Communication (AAC) Systems AAC devices are designed to allow individuals to communicate. As defined by the American Speech- Language Hearing Association (ASHA), an AAC device attempts to compensate for the impairment and disability patterns of individuals with severe, expressive communication disorders (i.e., individuals with severe speech-language and writing impairments). Dedicated AAC systems are designed specifically for a disabled population. Non-dedicated systems are commercially available devices such as laptop computers with special software and are not reimbursable by Medicaid.
Bathroom and Toileting Aids Bathroom and toileting aids are devices available to assist recipients who are incapable of using standard toilet facilities. Bedpans and urinals may be reimbursed when a recipient is confined to a bed. A portable commode may be reimbursed if a recipient has limited or no access to toilet facilities. A detachable or drop arm commode may be reimbursed if a recipient cannot perform a pivot transfer without assistance.
Compressors Compressors are machines that compress air into storage tanks for use by air-driven equipment. Medicaid may reimburse for an air power source compressor when it is used to support medically necessary DME that is not self-contained or with a nebulizer that provides at least 50 pounds per square inch (psi).
Custom Cranial Remolding Orthosis A custom cranial remolding orthosis is a non-invasive device used to correct the symmetry of an infant’s skull.
Disposable Incontinence Briefs, Diapers, Protective Underwear, Pull-Ons, Liners, Shields, Guards, Pads, Undergarments The disposable incontinence supplies as specified in this section are reimbursable only for use by individuals with chronic incontinence caused by a permanent physical or mental condition, including cerebral palsy and developmental delay.
Glucose Monitors, Diabetic Testing Strips, Insulin Syringes, and Blood Lancets Home glucose monitors, blood glucose, and urine keytone testing strips are covered for recipients whose documented medical condition requires frequent monitoring of urine or blood glucose levels. Insulin syringes are covered for recipients whose documented medical condition requires insulin to be injected. Blood lancets are used to pierce the skin for the purpose of obtaining a blood sample when monitoring blood glucose levels. Blood lancets are covered for recipients whose documented medical condition requires frequent monitoring of blood glucose levels.
Heat Lamps and Pads Heat lamps and heating pads are appliances or equipment used to apply heat to areas of the body. Medicaid covers heat lamps and heating pads when prescribed by a treating physician to treat a condition or illness that requires the application of localized heat therapy to affected area(s) of the body.
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Hospital Beds, Mattresses, and Rails A standard hospital bed consists of a modified latch spring assembly mattress, bed ends with casters, and two manually operated foot end cranks. It is equipped with IV sockets and is capable of accommodating a trapeze bar, side rails, an overhead frame, and other accessories. Medicaid may reimburse for a semi-electric bed or an electric bed when it is medically necessary for a recipient who is cognitively and physically capable of safely adjusting the position of the bed by independently operating the bed controls. Medicaid may reimburse for a heavy-duty bed for recipients weighing in excess of 350 pounds. Medicaid may reimburse for trapeze equipment when a recipient is confined and needs help to get in or out of bed, change their body position, or sit up for a respiratory condition.
Lymphedema Pump A non-segmental lymphedema pump is a device that has a single outflow port on the compressor that produces a set level of pressure. A segmental lymphedema pump is a device that has multiple outflow ports on the compressor that lead to distinct segments on the appliance that inflates sequentially.
Medical Supplies In addition to the above criteria, medical supplies to be reimbursed by Medicaid must be needed for use with one of the following: colostomy, urostomy, or ileostomy appliances; surgical, wound, and burn dressings; gastric feeding sets and supplies; urinary catheters, irrigation apparatus, and related items; tracheostomy and endotracheal care supplies; disposable items, which if not provided could reasonably cause the recipient to require emergency treatment, become hospitalized, or be placed in a long-term care facility; or in support of Medicaid-covered DME equipment used by the recipient.
Nebulizer A nebulizer is a device used to administer medication in the form of a mist into the respiratory system. Medicaid covers a nebulizer if the recipient’s ability to breathe is severely impaired. The authorized prescriber must document the name of the medication(s) to be used with the nebulizer on the prescription for the device.
Orthopedic Footwear Orthopedic footwear refers to footwear used in the preservation, restoration, and development of the form and function of the feet. Orthopedic footwear includes orthopedic shoes, shoe modifications, wedges, heels, and miscellaneous shoe additions. Foot orthotics are for congenital forefoot deformities in children who are under 18 months of age, unless determined medically necessary for an older child who is not yet walking.
Orthotic Device Orthotic devices are appliances that support or correct a weak or deformed body part or restrict or eliminate motion in a diseased or injured part of the body.
Osteogenesis Stimulator An osteogenesis stimulator is a device that provides electrical stimulation to augment bone repair. Medicaid may reimburse for an osteogenesis stimulator when non-union long bone fractures exceed three (3) months or when there is congenital pseudoarthrosis or failed fusion.
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Oxygen and Oxygen-Related Equipment Medicaid may reimburse oxygen and oxygen-related equipment, such as continuous positive airway pressure (CPAP) and bi-level pressure capability (BIPAP) devices, oxygen concentrators, or ventilators for recipients with hypoxia. Pulse oximeters are reimbursable for children who meet the eligibility criteria described under pulse oximeter in this section.
Parenteral and Drug Infusion Pumps Medicaid will reimburse for infusion pumps listed on the DME and Medical Supply Provider and Medical Supply Services Provider Fee Schedule for recipients under 21 years of age. A drug infusion pump is a device that is used to deliver solutions containing medication into the body at a regulated flow. An enteral feeding pump is a device that is used to deliver solutions containing enteral nutritional supplements into the recipient’s stomach or small intestine at a regulated flow.
Passive Motion Device A passive motion device is a mechanical device that is used to extend and flex the knee. Medicaid may reimburse for a passive motion device for recipients under 21 years of age who have undergone total knee arthroplasty (TKA) or reconstruction (open or arthroscopic repair) of the anterior cruciate ligament (ACL) of the knee.
Patient Lifts A patient lift is a portable device used to lift and transfer a recipient between a bed, a chair, wheelchair, or toilet with minimal personal assistance. Medicaid may reimburse for portable patient lifts for recipients under 21 years of age, for use in the recipient’s home, when the assistance of more than one person is necessary to move the recipient from bed to chair or chair to toilet, etc.; when recipient’s condition is such that periodic movement is necessary for effective treatment or care; or when device is used to prevent deterioration of a condition where the alternative is bed confinement.
Peak Flow Meter A peak flow meter measures how air flows from the lungs and is used in the medical management of asthma.
Pediatric Dynamic Splinting Device A pediatric dynamic splinting device is a device that is used to allow independent leg, knee, and hip motion and incrementally limit rotation of the feet. Medicaid may reimburse for a pediatric dynamic splinting device for clubfoot and internal tibial torsion.
Phototherapy (Bilirubin) Light with Photometer Phototherapy is the exposure to artificial light for treatment of neonatal jaundice.
Pressure Ulcer Care Medical equipment used to treat or prevent pressure ulcers. Medicaid may reimburse for pressure ulcer care pads and wheelchair cushions if the recipient currently has pressure ulcers or is highly susceptible to pressure
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
ulcers. Medicaid may reimburse for alternating pressure pads or mattresses and pumps for beds if a recipient is confined to a bed, has evidence of pressure ulcers, or provides evidence that the recipient is highly susceptible to pressure ulcers.
Prosthetic Devices and Eyes Prosthetic devices are artificial devices or appliances that replace all or part of a permanently inoperative or missing body part.
Pulse Oximeter A pulse oximeter is a non-invasive device used to measure blood oxygen levels. Medicaid may reimburse for the monthly rental of a medically necessary pulse oximeter to be used for the daily surveillance of complex newborns and children under the age of 6 between multiple scheduled surgical procedures to treat the recipient’s hypoplastic left heart syndrome (HLHS) condition and who are not receiving oxygen therapy services.
Resuscitator Bag A resuscitator bag is a hand-held device used to temporarily provide artificial breaths for recipients who cannot breathe unaided. When used, the attached bag filled with air is manually squeezed to force air into the recipient’s lungs. Medicaid may reimburse for a resuscitator bag when prescribed for a recipient who is ventilator dependent and using a ventilator owned by the recipient or a recipient who is non-ventilator dependent with a tracheostomy.
Suction Machines A suction machine is an electric aspirator designed for either upper respiratory and tracheal suction or gastric suction. Medicaid may reimburse for a stationary respiratory suction machine when the medical necessity documentation indicates in-home use is appropriate and use of the machine does not require technical or professional supervision. Medicaid may reimburse for a mobile respiratory suction machine in conjunction with a stationary model when medically necessary.
Traction Equipment Traction equipment is used to draw or pull sections of the body to improve skeletal alignment. Medicaid may reimburse for traction equipment when prescribed by the recipient’s treating physician or the treating physician’s prescribing ARNP or physician assistant for an orthopedic impairment requiring traction equipment that prevents ambulation during the period of use.
Ventilator and Respiratory Equipment Ventilator and respiratory equipment is used to support the respiratory system. Medicaid reimburses for the following ventilators and respiratory assist devices: continuous positive airway pressure device (CPAP); respiratory assist device, bi-level pressure capability, without back-up rate feature, used with noninvasive interface (BIPAP); respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface (BIPAP); intermittent positive pressure breathing machine (IPPB); volume ventilator;
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
negative pressure ventilator; or respiratory assist device, bi-level pressure capability, with back-up rate feature, used with invasive interface.
Wheelchairs A wheelchair is a seating device system mounted on wheels used to transport a non-ambulatory individual or an individual with severely limited mobility. Medicaid will reimburse for a wheelchair when the recipient is non-ambulatory or has severely limited mobility and it is medically documented that a wheelchair is medically necessary to accommodate the recipient’s physical characteristics. Medicaid will reimburse and provide maintenance for only one wheelchair (regardless of type) or power operated vehicle (POV) procedure code per recipient, per maximum limit period, as stated in the DME and Medical Supply Services Provider Fee Schedule. The following types of wheelchairs and POVs require prior authorization: customized manual wheelchairs, customized power wheelchairs, non-custom power wheelchairs, motorized scooters (POV), and power conversion kits.
Cover Code List
Category CPT Description Above Elbow, L6250 Above elbow, molded double wall socket, internal locking elbow, forearm Forearm and Hand Prosthetics Above the Knee L5200 Above knee, molded socket, single axis constant friction knee, shin, sach foot Prosthetics Above the Knee L5210 Above knee, short prosthesis, no knee joint ('stubbies'), with foot blocks, no Prosthetics ankle joints, each Above the Knee L5220 Above knee, short prosthesis, no knee joint ('stubbies'), with articulated Prosthetics ankle/foot, dynamically aligned, each Above the Knee L5230 Above knee, for proximal femoral focal deficiency, constant friction knee, shin, Prosthetics sach foot Accessories for E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or Oxygen Delivery greater oxygen concentration at the prescribed flow rate Devices Accessories for E1392 Portable oxygen concentrator, rental Oxygen Delivery Devices Accessories for E1399 Durable medical equipment, miscellaneous Oxygen Delivery Devices Accessories for L0970 Tlso, corset front Spinal Orthotics Accessories for L0972 Lso, corset front Spinal Orthotics Accessories for L0974 Tlso, full corset Spinal Orthotics
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Accessories for L0976 Lso, full corset Spinal Orthotics Accessories for L0978 Axillary crutch extension Spinal Orthotics Accessories for L0980 Peroneal straps, prefabricated, off-the-shelf, pair Spinal Orthotics Accessories for L0984 Protective body sock, prefabricated, off-the-shelf, each Spinal Orthotics Accessories for L0999 Addition to spinal orthosis, not otherwise specified Spinal Orthotics Additional L3912 Hand finger orthosis (hfo), flexion glove with elastic finger control, Miscellaneous prefabricated, off-the-shelf Orthotics, Upper Extremities Additional L3913 Hand finger orthosis, without joints, may include soft interface, straps, custom Miscellaneous fabricated, includes fitting and adjustment Orthotics, Upper Extremities Additional L3915 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, Miscellaneous turnbuckles, may include soft interface, straps, prefabricated item that has been Orthotics, Upper trimmed, bent, molded, assembled, or otherwise customized to fit a specific Extremities patient by an individual with expertise Additional L3916 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, Miscellaneous turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf Orthotics, Upper Extremities Additional L3923 Hand finger orthosis, without joints, may include soft interface, straps, Miscellaneous prefabricated item that has been trimmed, bent, molded, assembled, or Orthotics, Upper otherwise customized to fit a specific patient by an individual with expertise Extremities Additional L3924 Hand finger orthosis, without joints, may include soft interface, straps, Miscellaneous prefabricated, off-the-shelf Orthotics, Upper Extremities Additional L3925 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non Miscellaneous torsion joint/spring, extension/flexion, may include soft interface material, Orthotics, Upper prefabricated, off-the-shelf Extremities Additional L3929 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, Miscellaneous elastic bands/springs, may include soft interface material, straps, prefabricated Orthotics, Upper item that has been trimmed, bent, molded, assembled, or otherwise customized Extremities to fit a specific patient by an individual with expertise
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Additional L3931 Wrist hand finger orthosis, includes one or more nontorsion joint(s), Miscellaneous turnbuckles, elastic bands/springs, may include soft interface material, straps, Orthotics, Upper prefabricated, includes fitting and adjustment Extremities Additional L3933 Finger orthosis, without joints, may include soft interface, custom fabricated, Miscellaneous includes fitting and adjustment Orthotics, Upper Extremities Additions for L7400 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, Upper Extremity ultralight material (titanium, carbon fiber or equal) Prosthetics Additions for L7401 Addition to upper extremity prosthesis, above elbow disarticulation, ultralight Upper Extremity material (titanium, carbon fiber or equal) Prosthetics Additions for L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, Upper Extremity acrylic material Prosthetics Additions for L7404 Addition to upper extremity prosthesis, above elbow disarticulation, acrylic Upper Extremity material Prosthetics Additions, Lower L2200 Addition to lower extremity, limited ankle motion, each joint Extremity Orthotics Additions, Lower L2210 Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each Extremity joint Orthotics Additions, Lower L2220 Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each Extremity joint Orthotics Additions, Lower L2230 Addition to lower extremity, split flat caliper stirrups and plate attachment Extremity Orthotics Additions, Lower L2232 Addition to lower extremity orthosis, rocker bottom for total contact ankle foot Extremity orthosis, for custom fabricated orthosis only Orthotics Additions, Lower L2240 Addition to lower extremity, round caliper and plate attachment Extremity Orthotics Additions, Lower L2250 Addition to lower extremity, foot plate, molded to patient model, stirrup Extremity attachment Orthotics Additions, Lower L2260 Addition to lower extremity, reinforced solid stirrup (scott-craig type) Extremity Orthotics
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Additions, Lower L2265 Addition to lower extremity, long tongue stirrup Extremity Orthotics Additions, Lower L2270 Addition to lower extremity, varus/valgus correction ('t') strap, padded/lined or Extremity malleolus pad Orthotics Additions, Lower L2275 Addition to lower extremity, varus/valgus correction, plastic modification, Extremity padded/lined Orthotics Additions, Lower L2280 Addition to lower extremity, molded inner boot Extremity Orthotics Additions, Lower L2300 Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, Extremity adjustable Orthotics Additions, Lower L2310 Addition to lower extremity, abduction bar-straight Extremity Orthotics Additions, Lower L2320 Addition to lower extremity, non-molded lacer, for custom fabricated orthosis Extremity only Orthotics Additions, Lower L2330 Addition to lower extremity, lacer molded to patient model, for custom Extremity fabricated orthosis only Orthotics Additions, Lower L2335 Addition to lower extremity, anterior swing band Extremity Orthotics Additions, Lower L2340 Addition to lower extremity, pre-tibial shell, molded to patient model Extremity Orthotics Additions, Lower L2350 Addition to lower extremity, prosthetic type, (bk) socket, molded to patient Extremity model, (used for 'ptb' 'afo' orthoses) Orthotics Additions, Lower L2360 Addition to lower extremity, extended steel shank Extremity Orthotics Additions, Lower L2370 Addition to lower extremity, patten bottom Extremity Orthotics Additions, Lower L2375 Addition to lower extremity, torsion control, ankle joint and half solid stirrup Extremity Orthotics
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Additions, Lower L2380 Addition to lower extremity, torsion control, straight knee joint, each joint Extremity Orthotics Additions, Lower L2385 Addition to lower extremity, straight knee joint, heavy duty, each joint Extremity Orthotics Additions, Lower L2387 Addition to lower extremity, polycentric knee joint, for custom fabricated knee Extremity ankle foot orthosis, each joint Orthotics Additions, Lower L2390 Addition to lower extremity, offset knee joint, each joint Extremity Orthotics Additions, Lower L2395 Addition to lower extremity, offset knee joint, heavy duty, each joint Extremity Orthotics Additions, Lower L2397 Addition to lower extremity orthosis, suspension sleeve Extremity Orthotics Additions, Lower L2180 Addition to lower extremity fracture orthosis, plastic shoe insert with ankle Extremity, joints Fracture Orthotics Additions, Lower L2182 Addition to lower extremity fracture orthosis, drop lock knee joint Extremity, Fracture Orthotics Additions, Lower L2184 Addition to lower extremity fracture orthosis, limited motion knee joint Extremity, Fracture Orthotics Additions, Lower L2186 Addition to lower extremity fracture orthosis, adjustable motion knee joint, Extremity, lerman type Fracture Orthotics Additions, Lower L2188 Addition to lower extremity fracture orthosis, quadrilateral brim Extremity, Fracture Orthotics Additions, Lower L2190 Addition to lower extremity fracture orthosis, waist belt Extremity, Fracture Orthotics Additions, Lower L2192 Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh Extremity, flange, and pelvic belt Fracture Orthotics Additions, Pelvic L2570 Addition to lower extremity, pelvic control, hip joint, clevis type two position and/or Thoracic joint, each Control, Lower Extremities
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Additions, Pelvic L2580 Addition to lower extremity, pelvic control, pelvic sling and/or Thoracic Control, Lower Extremities Additions, Pelvic L2600 Addition to lower extremity, pelvic control, hip joint, clevis type, or thrust and/or Thoracic bearing, free, each Control, Lower Extremities Additions, Pelvic L2610 Addition to lower extremity, pelvic control, hip joint, clevis or thrust bearing, and/or Thoracic lock, each Control, Lower Extremities Additions, Pelvic L2620 Addition to lower extremity, pelvic control, hip joint, heavy duty, each and/or Thoracic Control, Lower Extremities Additions, Pelvic L2622 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each and/or Thoracic Control, Lower Extremities Additions, Pelvic L2624 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, and/or Thoracic extension, abduction control, each Control, Lower Extremities Additions, Pelvic L2627 Addition to lower extremity, pelvic control, plastic, molded to patient model, and/or Thoracic reciprocating hip joint and cables Control, Lower Extremities Additions, Pelvic L2628 Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and/or Thoracic and cables Control, Lower Extremities Additions, Pelvic L2630 Addition to lower extremity, pelvic control, band and belt, unilateral and/or Thoracic Control, Lower Extremities Additions, Pelvic L2640 Addition to lower extremity, pelvic control, band and belt, bilateral and/or Thoracic Control, Lower Extremities Additions, Pelvic L2650 Addition to lower extremity, pelvic and thoracic control, gluteal pad, each and/or Thoracic Control, Lower Extremities
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Additions, Pelvic L2660 Addition to lower extremity, thoracic control, thoracic band and/or Thoracic Control, Lower Extremities Additions, Pelvic L2670 Addition to lower extremity, thoracic control, paraspinal uprights and/or Thoracic Control, Lower Extremities Additions, Pelvic L2680 Addition to lower extremity, thoracic control, lateral support uprights and/or Thoracic Control, Lower Extremities Additions, L2500 Addition to lower extremity, thigh/weight bearing, gluteal/ ischial weight Weight-bearing, bearing, ring Lower Extremities Additions, L2510 Addition to lower extremity, thigh/weight bearing, quadri- lateral brim, molded Weight-bearing, to patient model Lower Extremities Additions, L2520 Addition to lower extremity, thigh/weight bearing, quadri- lateral brim, custom Weight-bearing, fitted Lower Extremities Additions, L2525 Addition to lower extremity, thigh/weight bearing, ischial containment/narrow Weight-bearing, m-l brim molded to patient model Lower Extremities Additions, L2526 Addition to lower extremity, thigh/weight bearing, ischial containment/narrow Weight-bearing, m-l brim, custom fitted Lower Extremities Additions, L2530 Addition to lower extremity, thigh-weight bearing, lacer, non-molded Weight-bearing, Lower Extremities Additions, L2540 Addition to lower extremity, thigh/weight bearing, lacer, molded to patient Weight-bearing, model Lower Extremities Additions, L2550 Addition to lower extremity, thigh/weight bearing, high roll cuff Weight-bearing, Lower Extremities
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Amputee E1170 Amputee wheelchair, fixed full length arms, swing away detachable elevating Wheelchairs legrests Amputee E1171 Amputee wheelchair, fixed full length arms, without footrests or legrest Wheelchairs Amputee E1172 Amputee wheelchair, detachable arms (desk or full length) without footrests or Wheelchairs legrest Amputee E1180 Amputee wheelchair, detachable arms (desk or full length) swing away Wheelchairs detachable footrests Amputee E1190 Amputee wheelchair, detachable arms (desk or full length) swing away Wheelchairs detachable elevating legrests Amputee E1195 Heavy duty wheelchair, fixed full length arms, swing away detachable elevating Wheelchairs legrests Amputee E1200 Amputee wheelchair, fixed full length arms, swing away detachable footrest Wheelchairs Ankle and/or Foot L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active Prosthetics and dorsiflexion feature Additions Ankle and/or Foot L5970 All lower extremity prostheses, foot, external keel, sach foot Prosthetics and Additions Ankle and/or Foot L5972 All lower extremity prostheses, foot, flexible keel Prosthetics and Additions Ankle and/or Foot L5974 All lower extremity prostheses, foot, single axis ankle/foot Prosthetics and Additions Ankle and/or Foot L5975 All lower extremity prosthesis, combination single axis ankle and flexible keel Prosthetics and foot Additions Ankle and/or Foot L5976 All lower extremity prostheses, energy storing foot (seattle carbon copy ii or Prosthetics and equal) Additions Ankle and/or Foot L5978 All lower extremity prostheses, foot, multiaxial ankle/foot Prosthetics and Additions Ankle and/or Foot L5979 All lower extremity prosthesis, multi-axial ankle, dynamic response foot, one Prosthetics and piece system Additions Ankle and/or Foot L5980 All lower extremity prostheses, flex foot system Prosthetics and Additions Ankle and/or Foot L5981 All lower extremity prostheses, flex-walk system or equal Prosthetics and Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Ankle and/or Foot L5982 All exoskeletal lower extremity prostheses, axial rotation unit Prosthetics and Additions Ankle and/or Foot L5984 All endoskeletal lower extremity prosthesis, axial rotation unit, with or without Prosthetics and adjustability Additions Ankle and/or Foot L5985 All endoskeletal lower extremity prostheses, dynamic prosthetic pylon Prosthetics and Additions Ankle and/or Foot L5986 All lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) Prosthetics and Additions Ankle and/or Foot L5987 All lower extremity prosthesis, shank foot system with vertical loading pylon Prosthetics and Additions Ankle and/or Foot L5988 Addition to lower limb prosthesis, vertical shock reducing pylon feature Prosthetics and Additions Ankle and/or Foot L5990 Addition to lower extremity prosthesis, user adjustable heel height Prosthetics and Additions Ankle and/or Foot L5999 Lower extremity prosthesis, not otherwise specified Prosthetics and Additions Ankle Prosthetics L5050 Ankle, symes, molded socket, sach foot Ankle Prosthetics L5060 Ankle, symes, metal frame, molded leather socket, articulated ankle/foot Ankle-foot L1900 Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated Orthotics Ankle-foot L1902 Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, Orthotics off-the-shelf Ankle-foot L1904 Ankle orthosis, ankle gauntlet or similar, with or without joints, custom Orthotics fabricated Ankle-foot L1906 Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf Orthotics Ankle-foot L1907 Ankle orthosis, supramalleolar with straps, with or without interface/pads, Orthotics custom fabricated Ankle-foot L1910 Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, Orthotics prefabricated, includes fitting and adjustment Ankle-foot L1920 Ankle foot orthosis, single upright with static or adjustable stop (phelps or Orthotics perlstein type), custom fabricated Ankle-foot L1930 Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and Orthotics adjustment Ankle-foot L1932 Afo, rigid anterior tibial section, total carbon fiber or equal material, Orthotics prefabricated, includes fitting and adjustment
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Ankle-foot L1940 Ankle foot orthosis, plastic or other material, custom fabricated Orthotics Ankle-foot L1945 Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom Orthotics fabricated Ankle-foot L1950 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, Orthotics custom fabricated Ankle-foot L1951 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or Orthotics other material, prefabricated, includes fitting and adjustment Ankle-foot L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated Orthotics Ankle-foot L1970 Ankle foot orthosis, plastic with ankle joint, custom fabricated Orthotics Ankle-foot L1971 Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, Orthotics includes fitting and adjustment Ankle-foot L1980 Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf Orthotics band/cuff (single bar 'bk' orthosis), custom fabricated Ankle-foot L1990 Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf Orthotics band/cuff (double bar 'bk' orthosis), custom fabricated Ankle-foot L2106 Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic Orthotics type casting material, custom fabricated Ankle-foot L2108 Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom Orthotics fabricated Ankle-foot L2112 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft, prefabricated, Orthotics includes fitting and adjustment Ankle-foot L2114 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, Orthotics prefabricated, includes fitting and adjustment Ankle-foot L2116 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, Orthotics prefabricated, includes fitting and adjustment Automated K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, External garment type Defibrillator and Supplies Bandages A6413 Adhesive bandage, first-aid type, any size, each Bandages A6441 Padding bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than five inches, per yard Bandages A6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard Bandages A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard Bandages A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5 inches, per yard Bandages A6445 Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Bandages A6446 Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard Bandages A6447 Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five inches, per yard Bandages A6448 Light compression bandage, elastic, knitted/woven, width less than three inches, per yard Bandages A6449 Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard Bandages A6450 Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard Bandages A6451 Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard Bandages A6452 High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard Bandages A6453 Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard Bandages A6454 Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard Bandages A6456 Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard Bandages A6457 Tubular dressing with or without elastic, any width, per linear yard Bathing Supplies E0240 Bath/shower chair, with or without wheels, any size Bathing Supplies E0241 Bath tub wall rail, each Bathing Supplies E0244 Raised toilet seat Bathing Supplies E0245 Tub stool or bench Bathing Supplies E0246 Transfer tub rail attachment Bathing Supplies E0247 Transfer bench for tub or toilet with or without commode opening Bathing Supplies E0248 Transfer bench, heavy duty, for tub or toilet with or without commode opening Bathing Supplies E0249 Pad for water circulating heat unit, for replacement only Batteries and L7360 Six volt battery, each Accessories Batteries and L7362 Battery charger, six volt, each Accessories Batteries and L7364 Twelve volt battery, each Accessories Batteries and L7366 Battery charger, twelve volt, each Accessories Below Elbow, L6100 Below elbow, molded socket, flexible elbow hinge, triceps pad Forearm and Hand Prosthetics
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Below Elbow, L6110 Below elbow, molded socket, (muenster or northwestern suspension types) Forearm and Hand Prosthetics Below Elbow, L6120 Below elbow, molded double wall split socket, step-up hinges, half cuff Forearm and Hand Prosthetics Below Elbow, L6130 Below elbow, molded double wall split socket, stump activated locking hinge, Forearm and half cuff Hand Prosthetics Below the Knee L5100 Below knee, molded socket, shin, sach foot Prosthetics Below the Knee L5105 Below knee, plastic socket, joints and thigh lacer, sach foot Prosthetics Breast Prosthetics L8000 Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, and Accessories any size, any type Breast Prosthetics L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, and Accessories unilateral, any size, any type Breast Prosthetics L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, and Accessories bilateral, any size, any type Breast Prosthetics L8010 Breast prosthesis, mastectomy sleeve and Accessories Breast Prosthetics L8015 External breast prosthesis garment, with mastectomy form, post mastectomy and Accessories Breast Prosthetics L8020 Breast prosthesis, mastectomy form and Accessories Breast Prosthetics L8030 Breast prosthesis, silicone or equal, without integral adhesive and Accessories Breast Pumps E0602 Breast pump, manual, any type Breast Pumps E0603 Breast pump, electric (ac and/or dc), any type Breast Pumps E0604 Breast pump, hospital grade, electric (ac and / or dc), any type Breathing Aids A7000 Canister, disposable, used with suction pump, each Breathing Aids A7001 Canister, non-disposable, used with suction pump, each Breathing Aids A7002 Tubing, used with suction pump, each Breathing Aids A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable Breathing Aids A7004 Small volume nonfiltered pneumatic nebulizer, disposable Breathing Aids A7005 Administration set, with small volume nonfiltered pneumatic nebulizer, non- disposable Breathing Aids A7006 Administration set, with small volume filtered pneumatic nebulizer Breathing Aids A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor Breathing Aids A7008 Large volume nebulizer, disposable, prefilled, used with aerosol compressor Breathing Aids A7009 Reservoir bottle, non-disposable, used with large volume ultrasonic nebulizer Breathing Aids A7010 Corrugated tubing, disposable, used with large volume nebulizer, 100 feet Breathing Aids A7012 Water collection device, used with large volume nebulizer
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Breathing Aids A7013 Filter, disposable, used with aerosol compressor or ultrasonic generator Breathing Aids A7014 Filter, nondisposable, used with aerosol compressor or ultrasonic generator Breathing Aids A7015 Aerosol mask, used with dme nebulizer Breathing Aids A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer Breathing Aids A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen Breathing Aids A7018 Water, distilled, used with large volume nebulizer, 1000 ml Breathing Aids A7020 Interface for cough stimulating device, includes all components, replacement only Breathing Aids A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each Breathing Aids A7028 Oral cushion for combination oral/nasal mask, replacement only, each Breathing Aids A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair Breathing Aids A7030 Full face mask used with positive airway pressure device, each Breathing Aids A7031 Face mask interface, replacement for full face mask, each Breathing Aids A7032 Cushion for use on nasal mask interface, replacement only, each Breathing Aids A7033 Pillow for use on nasal cannula type interface, replacement only, pair Breathing Aids A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap Breathing Aids A7035 Headgear used with positive airway pressure device Breathing Aids A7036 Chinstrap used with positive airway pressure device Breathing Aids A7037 Tubing used with positive airway pressure device Breathing Aids A7038 Filter, disposable, used with positive airway pressure device Breathing Aids A7039 Filter, non disposable, used with positive airway pressure device Breathing Aids A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each Breathing Aids A7048 Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each Cervical Halo L0810 Halo procedure, cervical halo incorporated into jacket vest Procedures Cervical Halo L0820 Halo procedure, cervical halo incorporated into plaster body jacket Procedures Cervical Halo L0830 Halo procedure, cervical halo incorporated into milwaukee type orthosis Procedures Cervical Halo L0859 Addition to halo procedure, magnetic resonance image compatible systems, Procedures rings and pins, any material Cervical L0113 Cranial cervical orthosis, torticollis type, with or without joint, with or without Orthotics soft interface material, prefabricated, includes fitting and adjustment Cervical L0120 Cervical, flexible, non-adjustable, prefabricated, off-the-shelf (foam collar) Orthotics Cervical L0130 Cervical, flexible, thermoplastic collar, molded to patient Orthotics Cervical L0140 Cervical, semi-rigid, adjustable (plastic collar) Orthotics
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Cervical L0150 Cervical, semi-rigid, adjustable molded chin cup (plastic collar with Orthotics mandibular/occipital piece) Cervical L0160 Cervical, semi-rigid, wire frame occipital/mandibular support, prefabricated, Orthotics off-the-shelf Cervical L0170 Cervical, collar, molded to patient model Orthotics Cervical L0172 Cervical, collar, semi-rigid thermoplastic foam, two-piece, prefabricated, off- Orthotics the-shelf Cervical L0174 Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic Orthotics extension, prefabricated, off-the-shelf Cervical L0180 Cervical, multiple post collar, occipital/mandibular supports, adjustable Orthotics Multi- post Collar Cervical L0190 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical Orthotics Multi- bars (somi, guilford, taylor types) post Collar Cervical L0200 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical Orthotics Multi- bars, and thoracic extension post Collar Cervical-thoracic- L0700 Cervical-thoracic-lumbar-sacral-orthoses (ctlso), anterior-posterior-lateral lumbar-sacral control, molded to patient model, (minerva type) Orthotics Cervical-thoracic- L0710 Ctlso, anterior-posterior-lateral-control, molded to patient model, with interface lumbar-sacral material, (minerva type) Orthotics Commode Chair E0163 Commode chair, mobile or stationary, with fixed arms and Supplies Commode Chair E0165 Commode chair, mobile or stationary, with detachable arms and Supplies Commode Chair E0167 Pail or pan for use with commode chair, replacement only and Supplies Commode Chair E0168 Commode chair, extra wide and/or heavy duty, stationary or mobile, with or and Supplies without arms, any type, each Commode Chair E0171 Commode chair with integrated seat lift mechanism, non-electric, any type and Supplies Communication E1902 Communication board, non-electronic augmentative or alternative Boards communication device Compression A6508 Compression burn garment, foot to thigh length, custom fabricated Garments and Stockings Compression A6512 Compression burn garment, not otherwise classified Garments and Stockings
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Compression A6530 Gradient compression stocking, below knee, 18-30 mmhg, each Garments and Stockings Compression A6531 Gradient compression stocking, below knee, 30-40 mmhg, each Garments and Stockings Compression A6532 Gradient compression stocking, below knee, 40-50 mmhg, each Garments and Stockings Compression A6533 Gradient compression stocking, thigh length, 18-30 mmhg, each Garments and Stockings Compression A6534 Gradient compression stocking, thigh length, 30-40 mmhg, each Garments and Stockings Compression A6535 Gradient compression stocking, thigh length, 40-50 mmhg, each Garments and Stockings Compression A6536 Gradient compression stocking, full length/chap style, 18-30 mmhg, each Garments and Stockings Compression A6537 Gradient compression stocking, full length/chap style, 30-40 mmhg, each Garments and Stockings Compression A6538 Gradient compression stocking, full length/chap style, 40-50 mmhg, each Garments and Stockings Compression A6539 Gradient compression stocking, waist length, 18-30 mmhg, each Garments and Stockings Compression A6540 Gradient compression stocking, waist length, 30-40 mmhg, each Garments and Stockings Compression A6541 Gradient compression stocking, waist length, 40-50 mmhg, each Garments and Stockings Compression A6545 Gradient compression wrap, non-elastic, below knee, 30-50 mm hg, each Garments and Stockings Compression A6550 Wound care set, for negative pressure wound therapy electrical pump, includes Garments and all supplies and accessories Stockings Cranial remolding S1040 Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom orthosis fabricated, includes fitting and adjustment(s)
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Customized K0900 Customized durable medical equipment, other than wheelchair DME, Other Than Wheelchair Custom-shaped L5704 Custom shaped protective cover, below knee Protective Covers Custom-shaped L5705 Custom shaped protective cover, above knee Protective Covers Custom-shaped L5706 Custom shaped protective cover, knee disarticulation Protective Covers Custom-shaped L5707 Custom shaped protective cover, hip disarticulation Protective Covers Diabetic A5500 For diabetics only, fitting (including follow-up), custom preparation and supply Footwear of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe Diabetic A5501 For diabetics only, fitting (including follow-up), custom preparation and supply Footwear of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe Diabetic A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay Footwear shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe Diabetic A5504 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay Footwear shoe or custom-molded shoe with wedge(s), per shoe Diabetic A5505 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay Footwear shoe or custom-molded shoe with metatarsal bar, per shoe Diabetic A5506 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay Footwear shoe or custom-molded shoe with off-set heel(s), per shoe Diabetic A5507 For diabetics only, not otherwise specified modification (including fitting) of Footwear off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe Diabetic A5512 For diabetics only, multiple density insert, direct formed, molded to foot after Footwear external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each Diabetic A5513 For diabetics only, multiple density insert, custom molded from model of Footwear patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each Diabetic A5514 For diabetics only, multiple density insert, made by direct carving with cam Footwear technology from a rectified cad model created from a digitized scan of the patient, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each Dialysis A4657 Syringe, with or without needle, each Equipment and Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Dialysis A4670 Automatic blood pressure monitor Equipment and Supplies Dialysis A4927 Gloves, non-sterile, per 100 Equipment and Supplies Dialysis A4928 Surgical mask, per 20 Equipment and Supplies Dialysis A4930 Gloves, sterile, per pair Equipment and Supplies Elbow L6200 Elbow disarticulation, molded socket, outside locking hinge, forearm Disarticulation, Forearm and Hand Prosthetics Elbow L6205 Elbow disarticulation, molded socket with expandable interface, outside locking Disarticulation, hinges, forearm Forearm and Hand Prosthetics Elbow Orthotics L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf Elbow Orthotics L3720 Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom fabricated Elbow Orthotics L3730 Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated Elbow Orthotics L3740 Elbow orthosis, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated Elbow Orthotics L3760 Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Elbow Orthotics L3761 Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off- the-shelf Elbow-wrist-hand L3762 Elbow orthosis, rigid, without joints, includes soft interface material, Orthotics prefabricated, off-the-shelf Elbow-wrist-hand L3763 Elbow wrist hand orthosis, rigid, without joints, may include soft interface, Orthotics straps, custom fabricated, includes fitting and adjustment Elbow-wrist-hand L3764 Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic Orthotics bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment Electric Hand or L7007 Electric hand, switch or myoelectric controlled, adult Hook and Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Electric Hand or L7008 Electric hand, switch or myoelectric, controlled, pediatric Hook and Additions Electric Hand or L7009 Electric hook, switch or myoelectric controlled, adult Hook and Additions Electric Hand or L7040 Prehensile actuator, switch controlled Hook and Additions Electric Hand or L7045 Electric hook, switch or myoelectric controlled, pediatric Hook and Additions Electronic Elbow L7170 Electronic elbow, hosmer or equal, switch controlled and Additions Electronic Elbow L7185 Electronic elbow, adolescent, variety village or equal, switch controlled and Additions Electronic Elbow L7186 Electronic elbow, child, variety village or equal, switch controlled and Additions Endoskeletal L5810 Addition, endoskeletal knee-shin system, single axis, manual lock Knee or Hip System Additions Endoskeletal L5811 Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light Knee or Hip material System Additions Endoskeletal L5812 Addition, endoskeletal knee-shin system, single axis, friction swing and stance Knee or Hip phase control (safety knee) System Additions Endoskeletal L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase Knee or Hip control, mechanical stance phase lock System Additions Endoskeletal L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase Knee or Hip lock System Additions Endoskeletal L5818 Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance Knee or Hip phase control System Additions Endoskeletal L5822 Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction Knee or Hip stance phase control System Additions Endoskeletal L5824 Addition, endoskeletal knee-shin system, single axis, fluid swing phase control Knee or Hip System Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Endoskeletal L5828 Addition, endoskeletal knee-shin system, single axis, fluid swing and stance Knee or Hip phase control System Additions Endoskeletal L5830 Addition, endoskeletal knee-shin system, single axis, pneumatic/ swing phase Knee or Hip control System Additions Endoskeletal L5840 Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic Knee or Hip swing phase control System Additions Endoskeletal L5845 Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable Knee or Hip System Additions Endoskeletal L5848 Addition to endoskeletal knee-shin system, fluid stance extension, dampening Knee or Hip feature, with or without adjustability System Additions Endoskeletal L5850 Addition, endoskeletal system, above knee or hip disarticulation, knee extension Knee or Hip assist System Additions Endoskeletal L5855 Addition, endoskeletal system, hip disarticulation, mechanical hip extension Knee or Hip assist System Additions Endoskeletal L5856 Addition to lower extremity prosthesis, endoskeletal knee-shin system, Knee or Hip microprocessor control feature, swing and stance phase, includes electronic System Additions sensor(s), any type Endoskeletal L5910 Addition, endoskeletal system, below knee, alignable system Knee or Hip System Additions Endoskeletal L5920 Addition, endoskeletal system, above knee or hip disarticulation, alignable Knee or Hip system System Additions Endoskeletal L5925 Addition, endoskeletal system, above knee, knee disarticulation or hip Knee or Hip disarticulation, manual lock System Additions Endoskeletal L5940 Addition, endoskeletal system, below knee, ultra-light material (titanium, Knee or Hip carbon fiber or equal) System Additions Endoskeletal L5950 Addition, endoskeletal system, above knee, ultra-light material (titanium, Knee or Hip carbon fiber or equal) System Additions Endoskeletal L5960 Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, Knee or Hip carbon fiber or equal) System Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Endoskeletal L5962 Addition, endoskeletal system, below knee, flexible protective outer surface Knee or Hip covering system System Additions Endoskeletal L5964 Addition, endoskeletal system, above knee, flexible protective outer surface Knee or Hip covering system System Additions Endoskeletal L5966 Addition, endoskeletal system, hip disarticulation, flexible protective outer Knee or Hip surface covering system System Additions Endoskeletal L5610 Addition to lower extremity, endoskeletal system, above knee, hydracadence Prosthetic system Additions, Lower Extremities Endoskeletal L5611 Addition to lower extremity, endoskeletal system, above knee - knee Prosthetic disarticulation, 4 bar linkage, with friction swing phase control Additions, Lower Extremities Endoskeletal L5613 Addition to lower extremity, endoskeletal system, above knee-knee Prosthetic disarticulation, 4 bar linkage, with hydraulic swing phase control Additions, Lower Extremities Endoskeletal L5616 Addition to lower extremity, endoskeletal system, above knee, universal Prosthetic multiplex system, friction swing phase control Additions, Lower Extremities Endoskeletal L5617 Addition to lower extremity, quick change self-aligning unit, above knee or Prosthetic below knee, each Additions, Lower Extremities Endoskeletal L5280 Hemipelvectomy, canadian type; molded socket, hip joint, single axis constant Prosthetics, friction knee, shin, sach foot Lower Limbs Endoskeletal L5301 Below knee, molded socket, shin, sach foot, endoskeletal system Prosthetics, Lower Limbs Endoskeletal L5312 Knee disarticulation (or through knee), molded socket, single axis knee, pylon, Prosthetics, sach foot, endoskeletal system Lower Limbs Endoskeletal L5321 Above knee, molded socket, open end, sach foot, endoskeletal system, single Prosthetics, axis knee Lower Limbs Endoskeletal L5331 Hip disarticulation, canadian type, molded socket, endoskeletal system, hip Prosthetics, joint, single axis knee, sach foot Lower Limbs
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Endoskeletal L5341 Hemipelvectomy, canadian type, molded socket, endoskeletal system, hip joint, Prosthetics, single axis knee, sach foot Lower Limbs Enteral Feeding B4034 Enteral feeding supply kit; syringe fed, per day, includes but not limited to Supplies and feeding/flushing syringe, administration set tubing, dressings, tape Equipment Enteral Feeding B4035 Enteral feeding supply kit; pump fed, per day, includes but not limited to Supplies and feeding/flushing syringe, administration set tubing, dressings, tape Equipment Enteral Feeding B4036 Enteral feeding supply kit; gravity fed, per day, includes but not limited to Supplies and feeding/flushing syringe, administration set tubing, dressings, tape Equipment Enteral Feeding B4081 Nasogastric tubing with stylet Supplies and Equipment Enteral Feeding B4082 Nasogastric tubing without stylet Supplies and Equipment Enteral Feeding B4083 Stomach tube - levine type Supplies and Equipment Enteral Feeding B4087 Gastrostomy/jejunostomy tube, standard, any material, any type, each Supplies and Equipment Enteral Feeding B4088 Gastrostomy/jejunostomy tube, low-profile, any material, any type, each Supplies and Equipment Enteral Formulas B4100 Food thickener, administered orally, per ounce and Additives Enteral Formulas B4102 Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear and Additives liquids), 500 ml = 1 unit Enteral Formulas B4103 Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear and Additives liquids), 500 ml = 1 unit Enteral Formulas B4104 Additive for enteral formula (e.g., fiber) and Additives Enteral Formulas B4105 In-line cartridge containing digestive enzyme(s) for enteral feeding, each and Additives Enteral Formulas B4149 Enteral formula, manufactured blenderized natural foods with intact nutrients, and Additives includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4150 Enteral formula, nutritionally complete with intact nutrients, includes proteins, and Additives fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Enteral Formulas B4152 Enteral formula, nutritionally complete, calorically dense (equal to or greater and Additives than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and and Additives peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4154 Enteral formula, nutritionally complete, for special metabolic needs, excludes and Additives inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4155 Enteral formula, nutritionally incomplete/modular nutrients, includes specific and Additives nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4157 Enteral formula, nutritionally complete, for special metabolic needs for and Additives inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4158 Enteral formula, for pediatrics, nutritionally complete with intact nutrients, and Additives includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4159 Enteral formula, for pediatrics, nutritionally complete soy based with intact and Additives nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4160 Enteral formula, for pediatrics, nutritionally complete calorically dense (equal and Additives to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain and Additives proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Enteral Formulas B4162 Enteral formula, for pediatrics, special metabolic needs for inherited disease of and Additives metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Exoskeletal L5710 Addition, exoskeletal knee-shin system, single axis, manual lock Knee-shin System Additions Exoskeletal L5711 Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light Knee-shin System material Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Exoskeletal L5712 Addition, exoskeletal knee-shin system, single axis, friction swing and stance Knee-shin System phase control (safety knee) Additions Exoskeletal L5714 Addition, exoskeletal knee-shin system, single axis, variable friction swing Knee-shin System phase control Additions Exoskeletal L5716 Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase Knee-shin System lock Additions Exoskeletal L5718 Addition, exoskeletal knee-shin system, polycentric, friction swing and stance Knee-shin System phase control Additions Exoskeletal L5722 Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction Knee-shin System stance phase control Additions Exoskeletal L5724 Addition, exoskeletal knee-shin system, single axis, fluid swing phase control Knee-shin System Additions Exoskeletal L5726 Addition, exoskeletal knee-shin system, single axis, external joints fluid swing Knee-shin System phase control Additions Exoskeletal L5728 Addition, exoskeletal knee-shin system, single axis, fluid swing and stance Knee-shin System phase control Additions Exoskeletal L5780 Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic Knee-shin System swing phase control Additions Extension/Flexion E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface Rehabilitation material Devices Extension/Flexion E1801 Static progressive stretch elbow device, extension and/or flexion, with or Rehabilitation without range of motion adjustment, includes all components and accessories Devices Extension/Flexion E1805 Dynamic adjustable wrist extension / flexion device, includes soft interface Rehabilitation material Devices Extension/Flexion E1806 Static progressive stretch wrist device, flexion and/or extension, with or without Rehabilitation range of motion adjustment, includes all components and accessories Devices Extension/Flexion E1810 Dynamic adjustable knee extension / flexion device, includes soft interface Rehabilitation material Devices
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Extension/Flexion E1811 Static progressive stretch knee device, extension and/or flexion, with or without Rehabilitation range of motion adjustment, includes all components and accessories Devices Extension/Flexion E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface Rehabilitation material Devices Extension/Flexion E1816 Static progressive stretch ankle device, flexion and/or extension, with or without Rehabilitation range of motion adjustment, includes all components and accessories Devices Extension/Flexion E1818 Static progressive stretch forearm pronation / supination device, with or without Rehabilitation range of motion adjustment, includes all components and accessories Devices Extension/Flexion E1820 Replacement soft interface material, dynamic adjustable extension/flexion Rehabilitation device Devices Extension/Flexion E1821 Replacement soft interface material/cuffs for bi-directional static progressive Rehabilitation stretch device Devices Extension/Flexion E1825 Dynamic adjustable finger extension/flexion device, includes soft interface Rehabilitation material Devices Extension/Flexion E1830 Dynamic adjustable toe extension/flexion device, includes soft interface Rehabilitation material Devices Extension/Flexion E1840 Dynamic adjustable shoulder flexion / abduction / rotation device, includes soft Rehabilitation interface material Devices External Power L6920 Wrist disarticulation, external power, self-suspended inner socket, removable Upper Limb forearm shell, otto bock or equal, switch, cables, two batteries and one charger, Prosthetics switch control of terminal device External Power L6925 Wrist disarticulation, external power, self-suspended inner socket, removable Upper Limb forearm shell, otto bock or equal electrodes, cables, two batteries and one Prosthetics charger, myoelectronic control of terminal device External Power L6930 Below elbow, external power, self-suspended inner socket, removable forearm Upper Limb shell, otto bock or equal switch, cables, two batteries and one charger, switch Prosthetics control of terminal device External Power L6935 Below elbow, external power, self-suspended inner socket, removable forearm Upper Limb shell, otto bock or equal electrodes, cables, two batteries and one charger, Prosthetics myoelectronic control of terminal device External Power L6940 Elbow disarticulation, external power, molded inner socket, removable humeral Upper Limb shell, outside locking hinges, forearm, otto bock or equal switch, cables, two Prosthetics batteries and one charger, switch control of terminal device
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
External Power L6945 Elbow disarticulation, external power, molded inner socket, removable humeral Upper Limb shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two Prosthetics batteries and one charger, myoelectronic control of terminal device External Power L6950 Above elbow, external power, molded inner socket, removable humeral shell, Upper Limb internal locking elbow, forearm, otto bock or equal switch, cables, two batteries Prosthetics and one charger, switch control of terminal device External Power L6955 Above elbow, external power, molded inner socket, removable humeral shell, Upper Limb internal locking elbow, forearm, otto bock or equal electrodes, cables, two Prosthetics batteries and one charger, myoelectronic control of terminal device External Power L6960 Shoulder disarticulation, external power, molded inner socket, removable Upper Limb shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Prosthetics otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device External Power L6965 Shoulder disarticulation, external power, molded inner socket, removable Upper Limb shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Prosthetics otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device External Power L6970 Interscapular-thoracic, external power, molded inner socket, removable Upper Limb shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Prosthetics otto bock or equal switch, cables, two batteries and one charger, switch control of terminal device External Power L6975 Interscapular-thoracic, external power, molded inner socket, removable Upper Limb shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Prosthetics otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device Eye Prosthetics V2623 Prosthetic eye, plastic, custom and Services Eye Prosthetics V2624 Polishing/resurfacing of ocular prosthesis and Services Eye Prosthetics V2625 Enlargement of ocular prosthesis and Services Eye Prosthetics V2626 Reduction of ocular prosthesis and Services Eye Prosthetics V2627 Scleral cover shell and Services Eye Prosthetics V2628 Fabrication and fitting of ocular conformer and Services Foam Dressings A6209 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing Foam Dressings A6210 Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Foam Dressings A6211 Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Foam Dressings A6212 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing Foam Dressings A6213 Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Foam Dressings A6214 Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing Foot Arch L3040 Foot, arch support, removable, premolded, longitudinal, each Supports Foot Arch L3050 Foot, arch support, removable, premolded, metatarsal, each Supports Foot Arch L3060 Foot, arch support, removable, premolded, longitudinal/ metatarsal, each Supports Foot Arch L3070 Foot, arch support, non-removable attached to shoe, longitudinal, each Supports Foot Arch L3080 Foot, arch support, non-removable attached to shoe, metatarsal, each Supports Foot Inserts, L3000 Foot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each Removable Foot Inserts, L3001 Foot, insert, removable, molded to patient model, spenco, each Removable Foot Inserts, L3002 Foot, insert, removable, molded to patient model, plastazote or equal, each Removable Foot Inserts, L3010 Foot, insert, removable, molded to patient model, longitudinal arch support, Removable each Foot Inserts, L3020 Foot, insert, removable, molded to patient model, longitudinal/ metatarsal Removable support, each Foot Inserts, L3030 Foot, insert, removable, formed to patient foot, each Removable Foot Inserts, L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high Removable strength, lightweight material, all hybrid lamination/prepreg composite, each Fracture, L3980 Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and Addition, and adjustment Unspecified Orthotics, Upper Extremities Fracture, L3982 Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting Addition, and and adjustment Unspecified Orthotics, Upper Extremities Fracture, L3984 Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and Addition, and adjustment Unspecified
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Orthotics, Upper Extremities Fracture, L3995 Addition to upper extremity orthosis, sock, fracture or equal, each Addition, and Unspecified Orthotics, Upper Extremities Fracture, L3999 Upper limb orthosis, not otherwise specified Addition, and Unspecified Orthotics, Upper Extremities Fully Reclining E1050 Fully-reclining wheelchair, fixed full length arms, swing away detachable Wheelchairs elevating leg rests Fully Reclining E1060 Fully-reclining wheelchair, detachable arms, desk or full length, swing away Wheelchairs detachable elevating legrests Fully Reclining E1070 Fully-reclining wheelchair, detachable arms (desk or full length) swing away Wheelchairs detachable footrest Gasket or Seal L7700 Gasket or seal, for use with prosthetic socket insert, any type, each with Prosthetic Gauze Dressings A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze Dressings A6219 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing Gauze Dressings A6220 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Gauze Dressings A6222 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze Dressings A6223 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze Dressings A6224 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 sq. in., without adhesive border, each dressing Gauze Dressings A6229 Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze Dressings A6231 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. in. or less, each dressing Gauze Dressings A6232 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. in., but less than or equal to 48 sq. in., each dressing Gauze Dressings A6233 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 sq. in., each dressing Hand Restoration L6890 Addition to upper extremity prosthesis, glove for terminal device, any material, Prosthetics and prefabricated, includes fitting and adjustment Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Hand Restoration L6900 Hand restoration (casts, shading and measurements included), partial hand, with Prosthetics and glove, thumb or one finger remaining Additions Hand Restoration L6905 Hand restoration (casts, shading and measurements included), partial hand, with Prosthetics and glove, multiple fingers remaining Additions Hand Restoration L6910 Hand restoration (casts, shading and measurements included), partial hand, with Prosthetics and glove, no fingers remaining Additions Hand Restoration L6915 Hand restoration (shading, and measurements included), replacement glove for Prosthetics and above Additions Heat, Cold, and E0202 Phototherapy (bilirubin) light with photometer Light Therapies Heat, Cold, and E0205 Heat lamp, with stand, includes bulb, or infrared element Light Therapies Heat, Cold, and E0210 Electric heat pad, standard Light Therapies Heat, Cold, and E0215 Electric heat pad, moist Light Therapies Heat, Cold, and E0217 Water circulating heat pad with pump Light Therapies Heat, Cold, and E0218 Fluid circulating cold pad with pump, any type Light Therapies Heat, Cold, and E0235 Paraffin bath unit, portable (see medical supply code a4265 for paraffin) Light Therapies Heat, Cold, and E0236 Pump for water circulating pad Light Therapies Heavy Duty and E1280 Heavy duty wheelchair, detachable arms (desk or full length) elevating legrests Special Wheelchairs Heavy Duty and E1285 Heavy duty wheelchair, fixed full length arms, swing away detachable footrest Special Wheelchairs Heavy Duty and E1290 Heavy duty wheelchair, detachable arms (desk or full length) swing away Special detachable footrest Wheelchairs Heavy Duty and E1295 Heavy duty wheelchair, fixed full length arms, elevating legrest Special Wheelchairs Heavy Duty and E1296 Special wheelchair seat height from floor Special Wheelchairs
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Heavy Duty and E1297 Special wheelchair seat depth, by upholstery Special Wheelchairs Heavy Duty and E1298 Special wheelchair seat depth and/or width, by construction Special Wheelchairs Heavy Duty, E1092 Wide heavy duty wheel chair, detachable arms (desk or full length), swing away Wide detachable elevating leg rests Wheelchairs Heavy Duty, E1093 Wide heavy duty wheelchair, detachable arms desk or full length arms, swing Wide away detachable footrests Wheelchairs Helmets A8000 Helmet, protective, soft, prefabricated, includes all components and accessories Helmets A8001 Helmet, protective, hard, prefabricated, includes all components and accessories Helmets A8002 Helmet, protective, soft, custom fabricated, includes all components and accessories Helmets A8003 Helmet, protective, hard, custom fabricated, includes all components and accessories Hemi- E1083 Hemi-wheelchair, fixed full length arms, swing away detachable elevating leg Wheelchairs rest Hemi- E1084 Hemi-wheelchair, detachable arms desk or full length arms, swing away Wheelchairs detachable elevating leg rests Hemi- E1085 Hemi-wheelchair, fixed full length arms, swing away detachable foot rests Wheelchairs Hemi- E1086 Hemi-wheelchair detachable arms desk or full length, swing away detachable Wheelchairs footrests Hernia Trusses L8300 Truss, single with standard pad Hernia Trusses L8310 Truss, double with standard pads Hip L5250 Hip disarticulation, canadian type; molded socket, hip joint, single axis constant Disarticulation friction knee, shin, sach foot Prosthetics Hip Orthotics L1600 Hip orthosis, abduction control of hip joints, flexible, frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an inidividual with expertise Hip Orthotics L1620 Hip orthosis, abduction control of hip joints, flexible, (pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Hip Orthotics L1630 Hip orthosis, abduction control of hip joints, semi-flexible (von rosen type), custom fabricated Hip Orthotics L1640 Hip orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated Hip Orthotics L1650 Hip orthosis, abduction control of hip joints, static, adjustable, (ilfled type), prefabricated, includes fitting and adjustment
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Hip Orthotics L1652 Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type Hip Orthotics L1660 Hip orthosis, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment Hip Orthotics L1680 Hip orthosis, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (rancho hip action type), custom fabricated Hip Orthotics L1685 Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated Hip Orthotics L1686 Hip orthosis, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment Hip Orthotics L1690 Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment Hip-knee-ankle- L2040 Hip knee ankle foot orthosis, torsion control, bilateral rotation straps, pelvic foot Orthotics band/belt, custom fabricated Hip-knee-ankle- L2050 Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, foot Orthotics pelvic band/belt, custom fabricated Hip-knee-ankle- L2060 Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, ball foot Orthotics bearing hip joint, pelvic band/ belt, custom fabricated Hip-knee-ankle- L2070 Hip knee ankle foot orthosis, torsion control, unilateral rotation straps, pelvic foot Orthotics band/belt, custom fabricated Hip-knee-ankle- L2080 Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, foot Orthotics pelvic band/belt, custom fabricated Hip-knee-ankle- L2090 Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, ball foot Orthotics bearing hip joint, pelvic band/ belt, custom fabricated Hospital Beds and E0250 Hospital bed, fixed height, with any type side rails, with mattress Associated Supplies Hospital Beds and E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress Associated Supplies Hospital Beds and E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, Associated with mattress Supplies Hospital Beds and E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, Associated without mattress Supplies Hospital Beds and E0265 Hospital bed, total electric (head, foot and height adjustments), with any type Associated side rails, with mattress Supplies Hospital Beds and E0271 Mattress, innerspring Associated Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Hospital Beds and E0272 Mattress, foam rubber Associated Supplies Hospital Beds and E0274 Over-bed table Associated Supplies Hospital Beds and E0275 Bed pan, standard, metal or plastic Associated Supplies Hospital Beds and E0276 Bed pan, fracture, metal or plastic Associated Supplies Hospital Beds and E0277 Powered pressure-reducing air mattress Associated Supplies Hospital Beds and E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, Associated without mattress Supplies Hospital Beds and E0297 Hospital bed, total electric (head, foot and height adjustments), without side Associated rails, without mattress Supplies Hospital Beds and E0301 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 Associated pounds, but less than or equal to 600 pounds, with any type side rails, without Supplies mattress Hospital Beds and E0303 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 Associated pounds, but less than or equal to 600 pounds, with any type side rails, with Supplies mattress Hospital Beds and E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than Associated 600 pounds, with any type side rails, with mattress Supplies Hospital Beds and E0305 Bed side rails, half length Associated Supplies Hospital Beds and E0310 Bed side rails, full length Associated Supplies Hospital Beds and E0315 Bed accessory: board, table, or support device, any type Associated Supplies Hospital Beds and E0316 Safety enclosure frame/canopy for use with hospital bed, any type Associated Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Hospital Beds and E0325 Urinal; male, jug-type, any material Associated Supplies Hospital Beds and E0326 Urinal; female, jug-type, any material Associated Supplies Hospital Beds and E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, Associated footboard and side rails up to 24 inches above the spring, includes mattress Supplies Hospital Beds and E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top Associated of headboard, footboard and side rails up to 24 inches above the spring, includes Supplies mattress Hospital Beds and E0350 Control unit for electronic bowel irrigation/evacuation system Associated Supplies Hospital Beds and E0352 Disposable pack (water reservoir bag, speculum, valving mechanism and Associated collection bag/box) for use with the electronic bowel irrigation/evacuation Supplies system Hospital Beds and E0370 Air pressure elevator for heel Associated Supplies Hospital Beds and E0371 Nonpowered advanced pressure reducing overlay for mattress, standard Associated mattress length and width Supplies Humidifiers and E0550 Humidifier, durable for extensive supplemental humidification during ippb Nebulizers with treatments or oxygen delivery Related Equipment Humidifiers and E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use with Nebulizers with regulator or flowmeter Related Equipment Humidifiers and E0560 Humidifier, durable for supplemental humidification during ippb treatment or Nebulizers with oxygen delivery Related Equipment Humidifiers and E0561 Humidifier, non-heated, used with positive airway pressure device Nebulizers with Related Equipment Humidifiers and E0562 Humidifier, heated, used with positive airway pressure device Nebulizers with Related Equipment
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Humidifiers and E0565 Compressor, air power source for equipment which is not self-contained or Nebulizers with cylinder driven Related Equipment Humidifiers and E0570 Nebulizer, with compressor Nebulizers with Related Equipment Humidifiers and E0572 Aerosol compressor, adjustable pressure, light duty for intermittent use Nebulizers with Related Equipment Humidifiers and E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer Nebulizers with Related Equipment Humidifiers and E0585 Nebulizer, with compressor and heater Nebulizers with Related Equipment Humidifiers and E0600 Respiratory suction pump, home model, portable or stationary, electric Nebulizers with Related Equipment Humidifiers and E0601 Continuous positive airway pressure (cpap) device Nebulizers with Related Equipment Hydrocolloid A6234 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without Dressings adhesive border, each dressing Hydrocolloid A6235 Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but Dressings less than or equal to 48 sq. in., without adhesive border, each dressing Hydrocolloid A6236 Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., Dressings without adhesive border, each dressing Hydrocolloid A6237 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any Dressings size adhesive border, each dressing Hydrocolloid A6238 Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but Dressings less than or equal to 48 sq. in., with any size adhesive border, each dressing Hydrocolloid A6240 Hydrocolloid dressing, wound filler, paste, sterile, per ounce Dressings Hydrocolloid A6241 Hydrocolloid dressing, wound filler, dry form, sterile, per gram Dressings Hydrogel A6242 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without Dressings adhesive border, each dressing
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Hydrogel A6243 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less Dressings than or equal to 48 sq. in., without adhesive border, each dressing Hydrogel A6244 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without Dressings adhesive border, each dressing Hydrogel A6245 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any Dressings size adhesive border, each dressing Hydrogel A6246 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less Dressings than or equal to 48 sq. in., with any size adhesive border, each dressing Hydrogel A6247 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., with any Dressings size adhesive border, each dressing Hydrogel A6248 Hydrogel dressing, wound filler, gel, per fluid ounce Dressings Iloprost, Q4074 Iloprost, inhalation solution, fda-approved final product, non-compounded, inhalation administered through dme, unit dose form, up to 20 micrograms solution Implantable Eye L8616 Microphone for use with cochlear implant device, replacement and Ear Prosthetics and Accessories Implantable Eye L8617 Transmitting coil for use with cochlear implant device, replacement and Ear Prosthetics and Accessories Implantable Eye L8618 Transmitter cable for use with cochlear implant device or auditory and Ear osseointegrated device, replacement Prosthetics and Accessories Implantable Eye L8619 Cochlear implant, external speech processor and controller, integrated system, and Ear replacement Prosthetics and Accessories Implantable Eye L8621 Zinc air battery for use with cochlear implant device and auditory and Ear osseointegrated sound processors, replacement, each Prosthetics and Accessories Implantable Eye L8624 Lithium ion battery for use with cochlear implant or auditory osseointegrated and Ear device speech processor, ear level, replacement, each Prosthetics and Accessories Implantable L8679 Implantable neurostimulator, pulse generator, any type neurostimulator, pulse generator
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Incontinence A4305 Disposable drug delivery system, flow rate of 50 ml or greater per hour Devices and Supplies Incontinence A4310 Insertion tray without drainage bag and without catheter (accessories only) Devices and Supplies Incontinence A4311 Insertion tray without drainage bag with indwelling catheter, foley type, two- Devices and way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) Supplies Incontinence A4312 Insertion tray without drainage bag with indwelling catheter, foley type, two- Devices and way, all silicone Supplies Incontinence A4313 Insertion tray without drainage bag with indwelling catheter, foley type, three- Devices and way, for continuous irrigation Supplies Incontinence A4314 Insertion tray with drainage bag with indwelling catheter, foley type, two-way Devices and latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.) Supplies Incontinence A4315 Insertion tray with drainage bag with indwelling catheter, foley type, two-way, Devices and all silicone Supplies Incontinence A4316 Insertion tray with drainage bag with indwelling catheter, foley type, three-way, Devices and for continuous irrigation Supplies Incontinence A4320 Irrigation tray with bulb or piston syringe, any purpose Devices and Supplies Incontinence A4322 Irrigation syringe, bulb or piston, each Devices and Supplies Incontinence A4326 Male external catheter with integral collection chamber, any type, each Devices and Supplies Incontinence A4327 Female external urinary collection device; meatal cup, each Devices and Supplies Incontinence A4328 Female external urinary collection device; pouch, each Devices and Supplies Incontinence A4330 Perianal fecal collection pouch with adhesive, each Devices and Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Incontinence A4331 Extension drainage tubing, any type, any length, with connector/adaptor, for use Devices and with urinary leg bag or urostomy pouch, each Supplies Incontinence A4332 Lubricant, individual sterile packet, each Devices and Supplies Incontinence A4333 Urinary catheter anchoring device, adhesive skin attachment, each Devices and Supplies Incontinence A4334 Urinary catheter anchoring device, leg strap, each Devices and Supplies Incontinence A4335 Incontinence supply; miscellaneous Devices and Supplies Incontinence A4337 Incontinence supply, rectal insert, any type, each Devices and Supplies Incontinence A4338 Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, Devices and silicone elastomer, or hydrophilic, etc.), each Supplies Incontinence A4340 Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.), each Devices and Supplies Incontinence A4344 Indwelling catheter, foley type, two-way, all silicone, each Devices and Supplies Incontinence A4346 Indwelling catheter; foley type, three way for continuous irrigation, each Devices and Supplies Incontinence A4349 Male external catheter, with or without adhesive, disposable, each Devices and Supplies Incontinence A4351 Intermittent urinary catheter; straight tip, with or without coating (teflon, Devices and silicone, silicone elastomer, or hydrophilic, etc.), each Supplies Incontinence A4352 Intermittent urinary catheter; coude (curved) tip, with or without coating (teflon, Devices and silicone, silicone elastomeric, or hydrophilic, etc.), each Supplies Incontinence A4353 Intermittent urinary catheter, with insertion supplies Devices and Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Incontinence A4354 Insertion tray with drainage bag but without catheter Devices and Supplies Incontinence A4355 Irrigation tubing set for continuous bladder irrigation through a three-way Devices and indwelling foley catheter, each Supplies Incontinence A4356 External urethral clamp or compression device (not to be used for catheter Devices and clamp), each Supplies Incontinence A4357 Bedside drainage bag, day or night, with or without anti-reflux device, with or Devices and without tube, each Supplies Incontinence A4358 Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, Devices and each Supplies Incontinence A5102 Bedside drainage bottle with or without tubing, rigid or expandable, each Devices and Supplies Incontinence A5105 Urinary suspensory with leg bag, with or without tube, each Devices and Supplies Incontinence A5112 Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, Devices and each Supplies Incontinence A5113 Leg strap; latex, replacement only, per set Devices and Supplies Incontinence A5114 Leg strap; foam or fabric, replacement only, per set Devices and Supplies Incontinence A5120 Skin barrier, wipes or swabs, each Devices and Supplies Incontinence A5121 Skin barrier; solid, 6 x 6 or equivalent, each Devices and Supplies Incontinence A5122 Skin barrier; solid, 8 x 8 or equivalent, each Devices and Supplies Incontinence A5126 Adhesive or non-adhesive; disk or foam pad Devices and Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Incontinence A5131 Appliance cleaner, incontinence and ostomy appliances, per 16 oz. Devices and Supplies Incontinence A5200 Percutaneous catheter/tube anchoring device, adhesive skin attachment Devices and Supplies Incontinence T4521 Adult sized disposable incontinence product, brief/diaper, small, each Supplies Incontinence T4522 Adult sized disposable incontinence product, brief/diaper, medium, each Supplies Incontinence T4523 Adult sized disposable incontinence product, brief/diaper, large, each Supplies Incontinence T4524 Adult sized disposable incontinence product, brief/diaper, extra large, each Supplies Incontinence T4525 Adult sized disposable incontinence product, protective underwear/pull-on, Supplies small size, each Incontinence T4526 Adult sized disposable incontinence product, protective underwear/pull-on, Supplies medium size, each Incontinence T4527 Adult sized disposable incontinence product, protective underwear/pull-on, Supplies large size, each Incontinence T4528 Adult sized disposable incontinence product, protective underwear/pull-on, Supplies extra large size, each Incontinence T4529 Pediatric sized disposable incontinence product, brief/diaper, small/medium Supplies size, each Incontinence T4530 Pediatric sized disposable incontinence product, brief/diaper, large size, each Supplies Incontinence T4531 Pediatric sized disposable incontinence product, protective underwear/pull-on, Supplies small/medium size, each Incontinence T4532 Pediatric sized disposable incontinence product, protective underwear/pull-on, Supplies large size, each Incontinence T4533 Youth sized disposable incontinence product, brief/diaper, each Supplies Incontinence T4534 Youth sized disposable incontinence product, protective underwear/pull-on, Supplies each Incontinence T4535 Disposable liner/shield/guard/pad/undergarment, for incontinence, each Supplies Incontinence T4537 Incontinence product, protective underpad, reusable, bed size, each Supplies Incontinence T4540 Incontinence product, protective underpad, reusable, chair size, each Supplies Incontinence T4541 Incontinence product, disposable underpad, large, each Supplies Incontinence T4542 Incontinence product, disposable underpad, small size, each Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Incontinence T4543 Adult sized disposable incontinence product, protective brief/diaper, above Supplies extra large, each Incontinence T4544 Adult sized disposable incontinence product, protective underwear/pull-on, Supplies above extra large, each Infusion Pumps E0776 Iv pole and Supplies Infusion Pumps E0779 Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or and Supplies greater Infusion Pumps E0780 Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours and Supplies Infusion Pumps E0781 Ambulatory infusion pump, single or multiple channels, electric or battery and Supplies operated, with administrative equipment, worn by patient Infusion Pumps E0783 Infusion pump system, implantable, programmable (includes all components, and Supplies e.g., pump, catheter, connectors, etc.) Infusion Pumps E0784 External ambulatory infusion pump, insulin and Supplies Infusion Pumps E0786 Implantable programmable infusion pump, replacement (excludes implantable and Supplies intraspinal catheter) Infusion Pumps E0791 Parenteral infusion pump, stationary, single or multi-channel and Supplies Infusion Pumps K0462 Temporary replacement for patient owned equipment being repaired, any type and Supplies Infusion Pumps K0552 Supplies for external non-insulin drug infusion pump, syringe type cartridge, and Supplies sterile, each Infusion Pumps K0553 Supply allowance for therapeutic continuous glucose monitor (cgm), includes and Supplies all supplies and accessories, 1 month supply = 1 unit of service Infusion Pumps K0554 Receiver (monitor), dedicated, for use with therapeutic glucose continuous and Supplies monitor system Infusion Pumps K0603 Replacement battery for external infusion pump owned by patient, alkaline, 1.5 and Supplies volt, each Injection and A4206 Syringe with needle, sterile, 1 cc or less, each Infusion Supplies Injection and A4207 Syringe with needle, sterile 2 cc, each Infusion Supplies Injection and A4208 Syringe with needle, sterile 3 cc, each Infusion Supplies Injection and A4209 Syringe with needle, sterile 5 cc or greater, each Infusion Supplies Injection and A4212 Non-coring needle or stylet with or without catheter Infusion Supplies Injection and A4213 Syringe, sterile, 20 cc or greater, each Infusion Supplies Injection and A4215 Needle, sterile, any size, each Infusion Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Injection and A4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml Infusion Supplies Injection and A4217 Sterile water/saline, 500 ml Infusion Supplies Injection and A4218 Sterile saline or water, metered dose dispenser, 10 ml Infusion Supplies Injection and A4220 Refill kit for implantable infusion pump Infusion Supplies Injection and A4221 Supplies for maintenance of non-insulin drug infusion catheter, per week (list Infusion Supplies drugs separately) Injection and A4222 Infusion supplies for external drug infusion pump, per cassette or bag (list drugs Infusion Supplies separately) Injection and A4223 Infusion supplies not used with external infusion pump, per cassette or bag (list Infusion Supplies drugs separately) Injection and A4224 Supplies for maintenance of insulin infusion catheter, per week Infusion Supplies Injection and A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each Infusion Supplies Injection and A4230 Infusion set for external insulin pump, non needle cannula type Infusion Supplies Injection and A4231 Infusion set for external insulin pump, needle type Infusion Supplies Injection and A4232 Syringe with needle for external insulin pump, sterile, 3 cc Infusion Supplies Insulin delivery S5560 Insulin delivery device, reusable pen; 1.5 ml size device Insulin delivery S5561 Insulin delivery device, reusable pen; 3 ml size device Insulin syringes S8490 Insulin syringes (100 syringes, any size) Intermittent E0500 Ippb machine, all types, with built-in nebulization; manual or automatic valves; Positive Pressure internal or external power source Breathing Devices Interscapular L6350 Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, Thoracic, Arm, internal locking elbow, forearm and Hand Prosthetics Interscapular L6360 Interscapular thoracic, passive restoration (complete prosthesis) Thoracic, Arm, and Hand Prosthetics Interscapular L6370 Interscapular thoracic, passive restoration (shoulder cap only) Thoracic, Arm,
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
and Hand Prosthetics Knee L5150 Knee disarticulation (or through knee), molded socket, external knee joints, Disarticulation shin, sach foot Prosthetics Knee L5160 Knee disarticulation (or through knee), molded socket, bent knee configuration, Disarticulation external knee joints, shin, sach foot Prosthetics Knee Orthotics L1810 Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee Orthotics L1812 Knee orthosis, elastic with joints, prefabricated, off-the-shelf Knee Orthotics L1820 Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment Knee Orthotics L1830 Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf Knee Orthotics L1831 Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment Knee Orthotics L1832 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee Orthotics L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf Knee Orthotics L1834 Knee orthosis, without knee joint, rigid, custom fabricated Knee Orthotics L1836 Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf Knee Orthotics L1840 Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated Knee Orthotics L1843 Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee Orthotics L1844 Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated Knee Orthotics L1845 Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee Orthotics L1846 Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Knee Orthotics L1847 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Knee Orthotics L1850 Knee orthosis, swedish type, prefabricated, off-the-shelf Knee Orthotics L1851 Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf Knee Orthotics L1852 Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf Knee Orthotics L1860 Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (sk) Knee-ankle-foot L2000 Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, Orthotics thigh and calf bands/cuffs (single bar 'ak' orthosis), custom fabricated Knee-ankle-foot L2010 Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf Orthotics bands/cuffs (single bar 'ak' orthosis), without knee joint, custom fabricated Knee-ankle-foot L2020 Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf Orthotics bands/cuffs (double bar 'ak' orthosis), custom fabricated Knee-ankle-foot L2030 Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf Orthotics bands/cuffs, (double bar 'ak' orthosis), without knee joint, custom fabricated Knee-ankle-foot L2034 Knee ankle foot orthosis, full plastic, single upright, with or without free motion Orthotics knee, medial lateral rotation control, with or without free motion ankle, custom fabricated Knee-ankle-foot L2036 Knee ankle foot orthosis, full plastic, double upright, with or without free Orthotics motion knee, with or without free motion ankle, custom fabricated Knee-ankle-foot L2037 Knee ankle foot orthosis, full plastic, single upright, with or without free motion Orthotics knee, with or without free motion ankle, custom fabricated Knee-ankle-foot L2038 Knee ankle foot orthosis, full plastic, with or without free motion knee, multi- Orthotics axis ankle, custom fabricated Knee-ankle-foot L2126 Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, Orthotics thermoplastic type casting material, custom fabricated Knee-ankle-foot L2128 Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, Orthotics custom fabricated Knee-ankle-foot L2132 Kafo, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, Orthotics includes fitting and adjustment Knee-ankle-foot L2134 Kafo, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, Orthotics includes fitting and adjustment Knee-ankle-foot L2136 Kafo, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, Orthotics includes fitting and adjustment Legg Perthes L1700 Legg perthes orthosis, (toronto type), custom fabricated Orthotics Legg Perthes L1710 Legg perthes orthosis, (newington type), custom fabricated Orthotics
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Legg Perthes L1720 Legg perthes orthosis, trilateral, (tachdijan type), custom fabricated Orthotics Legg Perthes L1730 Legg perthes orthosis, (scottish rite type), custom fabricated Orthotics Legg Perthes L1755 Legg perthes orthosis, (patten bottom type), custom fabricated Orthotics Lightweight E1240 Lightweight wheelchair, detachable arms, (desk or full length) swing away Wheelchairs detachable, elevating legrest Lightweight E1250 Lightweight wheelchair, fixed full length arms, swing away detachable footrest Wheelchairs Lightweight E1260 Lightweight wheelchair, detachable arms (desk or full length) swing away Wheelchairs detachable footrest Lightweight E1270 Lightweight wheelchair, fixed full length arms, swing away detachable Wheelchairs elevating legrests Lightweight, E1087 High strength lightweight wheelchair, fixed full length arms, swing away High-strength detachable elevating leg rests Wheelchairs Lightweight, E1088 High strength lightweight wheelchair, detachable arms desk or full length, High-strength swing away detachable elevating leg rests Wheelchairs Lightweight, E1089 High strength lightweight wheelchair, fixed length arms, swing away detachable High-strength footrest Wheelchairs Lightweight, E1090 High strength lightweight wheelchair, detachable arms desk or full length, High-strength swing away detachable foot rests Wheelchairs Low-profile L1200 Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis Additions, only Thoracic-lumbar- sacral Orthotics Low-profile L1210 Addition to tlso, (low profile), lateral thoracic extension Additions, Thoracic-lumbar- sacral Orthotics Low-profile L1220 Addition to tlso, (low profile), anterior thoracic extension Additions, Thoracic-lumbar- sacral Orthotics Low-profile L1230 Addition to tlso, (low profile), milwaukee type superstructure Additions, Thoracic-lumbar- sacral Orthotics Low-profile L1240 Addition to tlso, (low profile), lumbar derotation pad Additions,
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Thoracic-lumbar- sacral Orthotics Low-profile L1250 Addition to tlso, (low profile), anterior asis pad Additions, Thoracic-lumbar- sacral Orthotics Low-profile L1260 Addition to tlso, (low profile), anterior thoracic derotation pad Additions, Thoracic-lumbar- sacral Orthotics Low-profile L1270 Addition to tlso, (low profile), abdominal pad Additions, Thoracic-lumbar- sacral Orthotics Low-profile L1280 Addition to tlso, (low profile), rib gusset (elastic), each Additions, Thoracic-lumbar- sacral Orthotics Low-profile L1290 Addition to tlso, (low profile), lateral trochanteric pad Additions, Thoracic-lumbar- sacral Orthotics Lumbar Orthotics L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf Lumbar Orthotics L0626 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar Orthotics L0627 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar Orthotics L0641 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends Sagittal Control from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar Orthotics L0642 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, Sagittal Control posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the- shelf Lumbar-sacral L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior Orthotics extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar-sacral L0629 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior Orthotics extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral L0630 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior Orthotics extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral L0631 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, Orthotics posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral L0637 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and Orthotics posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Lumbar-sacral L0648 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, Orthotics Sagittal posterior extends from sacrococcygeal junction to t-9 vertebra, produces Control intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf Lumbar-sacral L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and Orthotics Sagittal posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 Control vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Lumbar-sacral L0651 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior Orthotics Sagittal extends from sacrococcygeal junction to t-9 vertebra, anterior extends from Control symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf Manual E2201 Manual wheelchair accessory, nonstandard seat frame, width greater than or Wheelchair equal to 20 inches and less than 24 inches Accessories Manual E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches Wheelchair Accessories Manual E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 Wheelchair inches Accessories Manual E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches Wheelchair Accessories Manual E2205 Manual wheelchair accessory, handrim without projections (includes ergonomic Wheelchair or contoured), any type, replacement only, each Accessories Manual E2206 Manual wheelchair accessory, wheel lock assembly, complete, replacement Wheelchair only, each Accessories Manual E2207 Wheelchair accessory, crutch and cane holder, each Wheelchair Accessories Manual E2208 Wheelchair accessory, cylinder tank carrier, each Wheelchair Accessories Manual E2209 Accessory, arm trough, with or without hand support, each Wheelchair Accessories Manual E2210 Wheelchair accessory, bearings, any type, replacement only, each Wheelchair Accessories Manual E2211 Manual wheelchair accessory, pneumatic propulsion tire, any size, each Wheelchair Accessories Manual E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each Wheelchair Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Manual E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), Wheelchair any type, any size, each Accessories Manual E2214 Manual wheelchair accessory, pneumatic caster tire, any size, each Wheelchair Accessories Manual E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any size, each Wheelchair Accessories Manual E2216 Manual wheelchair accessory, foam filled propulsion tire, any size, each Wheelchair Accessories Manual E2217 Manual wheelchair accessory, foam filled caster tire, any size, each Wheelchair Accessories Manual E2218 Manual wheelchair accessory, foam propulsion tire, any size, each Wheelchair Accessories Manual E2219 Manual wheelchair accessory, foam caster tire, any size, each Wheelchair Accessories Manual E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, Wheelchair replacement only, each Accessories Manual E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any Wheelchair size, replacement only, each Accessories Manual E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any size, Wheelchair replacement only, each Accessories Manual E2225 Manual wheelchair accessory, caster wheel excludes tire, any size, replacement Wheelchair only, each Accessories Manual E2226 Manual wheelchair accessory, caster fork, any size, replacement only, each Wheelchair Accessories Manual E2227 Manual wheelchair accessory, gear reduction drive wheel, each Wheelchair Accessories Manual E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each Wheelchair Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Manual E2231 Manual wheelchair accessory, solid seat support base (replaces sling seat), Wheelchair includes any type mounting hardware Accessories Manual E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware Wheelchair Accessories Manual E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware Wheelchair Accessories Manual E2293 Back, contoured, for pediatric size wheelchair including fixed attaching Wheelchair hardware Accessories Miscellaneous K0733 Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each DME and (e.g., gel cell, absorbed glassmat) Accessories Miscellaneous K0738 Portable gaseous oxygen system, rental; home compressor used to fill portable DME and oxygen cylinders; includes portable containers, regulator, flowmeter, Accessories humidifier, cannula or mask, and tubing Miscellaneous K0739 Repair or nonroutine service for durable medical equipment other than oxygen DME and equipment requiring the skill of a technician, labor component, per 15 minutes Accessories Miscellaneous A9900 Miscellaneous dme supply, accessory, and/or service component of another DME Supplies hcpcs code and Services Miscellaneous A9901 Dme delivery, set up, and/or dispensing service component of another hcpcs DME Supplies code and Services Miscellaneous A9999 Miscellaneous dme supply or accessory, not otherwise specified DME Supplies and Services Miscellaneous A6010 Collagen based wound filler, dry form, sterile, per gram of collagen Dressing and Wound Supplies Miscellaneous A6011 Collagen based wound filler, gel/paste, per gram of collagen Dressing and Wound Supplies Miscellaneous A6021 Collagen dressing, sterile, size 16 sq. in. or less, each Dressing and Wound Supplies Miscellaneous A6022 Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 Dressing and sq. in., each Wound Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Miscellaneous A6023 Collagen dressing, sterile, size more than 48 sq. in., each Dressing and Wound Supplies Miscellaneous A6024 Collagen dressing wound filler, sterile, per 6 inches Dressing and Wound Supplies Miscellaneous A6154 Wound pouch, each Dressing and Wound Supplies Miscellaneous A6196 Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. Dressing and or less, each dressing Wound Supplies Miscellaneous A6197 Alginate or other fiber gelling dressing, wound cover, sterile, pad size more Dressing and than 16 sq. in. but less than or equal to 48 sq. in., each dressing Wound Supplies Miscellaneous A6198 Alginate or other fiber gelling dressing, wound cover, sterile, pad size more Dressing and than 48 sq. in., each dressing Wound Supplies Miscellaneous A6199 Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches Dressing and Wound Supplies Miscellaneous A6203 Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive Dressing and border, each dressing Wound Supplies Miscellaneous A6204 Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal Dressing and to 48 sq. in., with any size adhesive border, each dressing Wound Supplies Miscellaneous A6206 Contact layer, sterile, 16 sq. in. or less, each dressing Dressing and Wound Supplies Miscellaneous A6207 Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., Dressing and each dressing Wound Supplies Miscellaneous L8692 Auditory osseointegrated device, external sound processor, used without Orthotic and osseointegration, body worn, includes headband or other means of external Prosthetic attachment Services and Supplies Miscellaneous L9900 Orthotic and prosthetic supply, accessory, and/or service component of another Orthotic and hcpcs "l" code Prosthetic Services and Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Miscellaneous E2000 Gastric suction pump, home model, portable or stationary, electric Pumps and Monitors Miscellaneous E2100 Blood glucose monitor with integrated voice synthesizer Pumps and Monitors Miscellaneous E2101 Blood glucose monitor with integrated lancing/blood sample Pumps and Monitors Miscellaneous A9270 Non-covered item or service Supplies and Equipment Miscellaneous A9274 External ambulatory insulin delivery system, disposable, each, includes all Supplies and supplies and accessories Equipment Miscellaneous A9276 Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial Supplies and continuous glucose monitoring system, one unit = 1 day supply Equipment Miscellaneous A9277 Transmitter; external, for use with interstitial continuous glucose monitoring Supplies and system Equipment Miscellaneous A9278 Receiver (monitor); external, for use with interstitial continuous glucose Supplies and monitoring system Equipment Miscellaneous A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all Supplies and accessories, components and electronics, not otherwise classified Equipment Miscellaneous A9281 Reaching/grabbing device, any type, any length, each Supplies and Equipment Miscellaneous A9284 Spirometer, non-electronic, includes all accessories Supplies and Equipment Miscellaneous A9286 Hygienic item or device, disposable or non-disposable, any type, each Supplies and Equipment Molded Socket L6400 Below elbow, molded socket, endoskeletal system, including soft prosthetic Endoskeletal tissue shaping Prosthetic System, Upper Limbs Molded Socket L6450 Elbow disarticulation, molded socket, endoskeletal system, including soft Endoskeletal prosthetic tissue shaping Prosthetic
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
System, Upper Limbs Molded Socket L6500 Above elbow, molded socket, endoskeletal system, including soft prosthetic Endoskeletal tissue shaping Prosthetic System, Upper Limbs Molded Socket L6550 Shoulder disarticulation, molded socket, endoskeletal system, including soft Endoskeletal prosthetic tissue shaping Prosthetic System, Upper Limbs Molded Socket L6570 Interscapular thoracic, molded socket, endoskeletal system, including soft Endoskeletal prosthetic tissue shaping Prosthetic System, Upper Limbs Monitoring E0607 Home blood glucose monitor Equipment Monitoring E0618 Apnea monitor, without recording feature Equipment Monitoring E0619 Apnea monitor, with recording feature Equipment Nutrition Infusion B9002 Enteral nutrition infusion pump, any type Pumps and Supplies Not Otherwise Classified, NOC Nutrition Infusion B9004 Parenteral nutrition infusion pump, portable Pumps and Supplies Not Otherwise Classified, NOC Nutrition Infusion B9006 Parenteral nutrition infusion pump, stationary Pumps and Supplies Not Otherwise Classified, NOC Nutrition Infusion B9998 Noc for enteral supplies Pumps and Supplies Not Otherwise Classified, NOC Orthopedic Shoes L3201 Orthopedic shoe, oxford with supinator or pronator, infant
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Orthopedic Shoes L3202 Orthopedic shoe, oxford with supinator or pronator, child Orthopedic Shoes L3203 Orthopedic shoe, oxford with supinator or pronator, junior Orthopedic Shoes L3204 Orthopedic shoe, hightop with supinator or pronator, infant Orthopedic Shoes L3206 Orthopedic shoe, hightop with supinator or pronator, child Orthopedic Shoes L3207 Orthopedic shoe, hightop with supinator or pronator, junior Orthosis L3600 Transfer of an orthosis from one shoe to another, caliper plate, existing Transfers Orthosis L3610 Transfer of an orthosis from one shoe to another, caliper plate, new Transfers Orthosis L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing Transfers Orthosis L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new Transfers Orthosis L3640 Transfer of an orthosis from one shoe to another, dennis browne splint (riveton), Transfers both shoes Orthosis L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified Transfers Orthotic L2405 Addition to knee joint, drop lock, each Additions to Knee Joints Orthotic L2415 Addition to knee lock with integrated release mechanism (bail, cable, or equal), Additions to Knee any material, each joint Joints Orthotic L2425 Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint Additions to Knee Joints Orthotic L2430 Addition to knee joint, ratchet lock for active and progressive knee extension, Additions to Knee each joint Joints Orthotic L2492 Addition to knee joint, lift loop for drop lock ring Additions to Knee Joints Orthotic L4000 Replace girdle for spinal orthosis (ctlso or so) Replacement Parts or Repair Orthotic L4002 Replacement strap, any orthosis, includes all components, any length, any type Replacement Parts or Repair Orthotic L4010 Replace trilateral socket brim Replacement Parts or Repair Orthotic L4020 Replace quadrilateral socket brim, molded to patient model Replacement Parts or Repair
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Orthotic L4030 Replace quadrilateral socket brim, custom fitted Replacement Parts or Repair Orthotic L4040 Replace molded thigh lacer, for custom fabricated orthosis only Replacement Parts or Repair Orthotic L4045 Replace non-molded thigh lacer, for custom fabricated orthosis only Replacement Parts or Repair Orthotic L4050 Replace molded calf lacer, for custom fabricated orthosis only Replacement Parts or Repair Orthotic L4055 Replace non-molded calf lacer, for custom fabricated orthosis only Replacement Parts or Repair Orthotic L4060 Replace high roll cuff Replacement Parts or Repair Orthotic L4070 Replace proximal and distal upright for kafo Replacement Parts or Repair Orthotic L4080 Replace metal bands kafo, proximal thigh Replacement Parts or Repair Orthotic L4090 Replace metal bands kafo-afo, calf or distal thigh Replacement Parts or Repair Orthotic L4100 Replace leather cuff kafo, proximal thigh Replacement Parts or Repair Orthotic L4110 Replace leather cuff kafo-afo, calf or distal thigh Replacement Parts or Repair Orthotic L4130 Replace pretibial shell Replacement Parts or Repair Orthotic L4205 Repair of orthotic device, labor component, per 15 minutes Replacement Parts or Repair Orthotic L4210 Repair of orthotic device, repair or replace minor parts Replacement Parts or Repair Ostomy Pouches A4362 Skin barrier; solid, 4 x 4 or equivalent; each and Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Ostomy Pouches A4363 Ostomy clamp, any type, replacement only, each and Supplies Ostomy Pouches A4364 Adhesive, liquid or equal, any type, per oz and Supplies Ostomy Pouches A4367 Ostomy belt, each and Supplies Ostomy Pouches A4369 Ostomy skin barrier, liquid (spray, brush, etc.), per oz and Supplies Ostomy Pouches A4371 Ostomy skin barrier, powder, per oz and Supplies Ostomy Pouches A4372 Ostomy skin barrier, solid 4 x 4 or equivalent, standard wear, with built-in and Supplies convexity, each Ostomy Pouches A4373 Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in and Supplies convexity, any size, each Ostomy Pouches A4375 Ostomy pouch, drainable, with faceplate attached, plastic, each and Supplies Ostomy Pouches A4385 Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in and Supplies convexity, each Ostomy Pouches A4388 Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each and Supplies Ostomy Pouches A4389 Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 and Supplies piece), each Ostomy Pouches A4390 Ostomy pouch, drainable, with extended wear barrier attached, with built-in and Supplies convexity (1 piece), each Ostomy Pouches A4391 Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each and Supplies Ostomy Pouches A4392 Ostomy pouch, urinary, with standard wear barrier attached, with built-in and Supplies convexity (1 piece), each Ostomy Pouches A4393 Ostomy pouch, urinary, with extended wear barrier attached, with built-in and Supplies convexity (1 piece), each Ostomy Pouches A4394 Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid and Supplies ounce Ostomy Pouches A4396 Ostomy belt with peristomal hernia support and Supplies Ostomy Pouches A4397 Irrigation supply; sleeve, each and Supplies Ostomy Pouches A4398 Ostomy irrigation supply; bag, each and Supplies Ostomy Pouches A4399 Ostomy irrigation supply; cone/catheter, with or without brush and Supplies Ostomy Pouches A4400 Ostomy irrigation set and Supplies Ostomy Pouches A4402 Lubricant, per ounce and Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Ostomy Pouches A4404 Ostomy ring, each and Supplies Ostomy Pouches A4405 Ostomy skin barrier, non-pectin based, paste, per ounce and Supplies Ostomy Pouches A4406 Ostomy skin barrier, pectin-based, paste, per ounce and Supplies Ostomy Pouches A4407 Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, and Supplies with built-in convexity, 4 x 4 inches or smaller, each Ostomy Pouches A4408 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, and Supplies with built-in convexity, larger than 4 x 4 inches, each Ostomy Pouches A4409 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, and Supplies without built-in convexity, 4 x 4 inches or smaller, each Ostomy Pouches A4410 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, and Supplies without built-in convexity, larger than 4 x 4 inches, each Ostomy Pouches A4411 Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in and Supplies convexity, each Ostomy Pouches A4413 Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece and Supplies system), with filter, each Ostomy Pouches A4414 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in and Supplies convexity, 4 x 4 inches or smaller, each Ostomy Pouches A4415 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in and Supplies convexity, larger than 4 x 4 inches, each Ostomy Pouches A4416 Ostomy pouch, closed, with barrier attached, with filter (1 piece), each and Supplies Ostomy Pouches A4417 Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter and Supplies (1 piece), each Ostomy Pouches A4418 Ostomy pouch, closed; without barrier attached, with filter (1 piece), each and Supplies Ostomy Pouches A4419 Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 and Supplies piece), each Ostomy Pouches A4421 Ostomy supply; miscellaneous and Supplies Ostomy Pouches A4422 Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch and Supplies to thicken liquid stomal output, each Ostomy Pouches A4423 Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 and Supplies piece), each Ostomy Pouches A4424 Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each and Supplies Ostomy Pouches A4425 Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter and Supplies (2 piece system), each Ostomy Pouches A4426 Ostomy pouch, drainable; for use on barrier with locking flange (2 piece and Supplies system), each Ostomy Pouches A4427 Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 and Supplies piece system), each
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Ostomy Pouches A4430 Ostomy pouch, urinary, with extended wear barrier attached, with built-in and Supplies convexity, with faucet-type tap with valve (1 piece), each Ostomy Pouches A4432 Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet- and Supplies type tap with valve (2 piece), each Ostomy Pouches A4433 Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each and Supplies Ostomy Pouches A4435 Ostomy pouch, drainable, high output, with extended wear barrier (one-piece and Supplies system), with or without filter, each Ostomy Pouches A5051 Ostomy pouch, closed; with barrier attached (1 piece), each and Supplies Ostomy Pouches A5052 Ostomy pouch, closed; without barrier attached (1 piece), each and Supplies Ostomy Pouches A5054 Ostomy pouch, closed; for use on barrier with flange (2 piece), each and Supplies Ostomy Pouches A5055 Stoma cap and Supplies Ostomy Pouches A5056 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 and Supplies piece), each Ostomy Pouches A5057 Ostomy pouch, drainable, with extended wear barrier attached, with built in and Supplies convexity, with filter, (1 piece), each Ostomy Pouches A5061 Ostomy pouch, drainable; with barrier attached, (1 piece), each and Supplies Ostomy Pouches A5062 Ostomy pouch, drainable; without barrier attached (1 piece), each and Supplies Ostomy Pouches A5063 Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each and Supplies Ostomy Pouches A5071 Ostomy pouch, urinary; with barrier attached (1 piece), each and Supplies Ostomy Pouches A5073 Ostomy pouch, urinary; for use on barrier with flange (2 piece), each and Supplies Other Breathing E0605 Vaporizer, room type Aids Other Breathing E0606 Postural drainage board Aids Other Dressings, A6250 Skin sealants, protectants, moisturizers, ointments, any type, any size Coverings, and Wound Treatment Supplies Other Dressings, A6251 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, Coverings, and without adhesive border, each dressing Wound Treatment Supplies Other Dressings, A6252 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. Coverings, and in. but less than or equal to 48 sq. in., without adhesive border, each dressing
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wound Treatment Supplies Other Dressings, A6253 Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. Coverings, and in., without adhesive border, each dressing Wound Treatment Supplies Other Dressings, A6254 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, Coverings, and with any size adhesive border, each dressing Wound Treatment Supplies Other Dressings, A6255 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. Coverings, and in. but less than or equal to 48 sq. in., with any size adhesive border, each Wound Treatment dressing Supplies Other Dressings, A6257 Transparent film, sterile, 16 sq. in. or less, each dressing Coverings, and Wound Treatment Supplies Other Dressings, A6258 Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., Coverings, and each dressing Wound Treatment Supplies Other Dressings, A6259 Transparent film, sterile, more than 48 sq. in., each dressing Coverings, and Wound Treatment Supplies Other Dressings, A6260 Wound cleansers, any type, any size Coverings, and Wound Treatment Supplies Other Dressings, A6266 Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any Coverings, and width, per linear yard Wound Treatment Supplies Other Dressings, A6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive Coverings, and border, each dressing Wound Treatment Supplies Other Dressings, A6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. less than or equal Coverings, and to 48 sq. in., without adhesive border, each dressing Wound Treatment Supplies Other Dressings, A6407 Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard Coverings, and
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wound Treatment Supplies Other Dressings, A6412 Eye patch, occlusive, each Coverings, and Wound Treatment Supplies Other Exoskeletal L5785 Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon Additions fiber or equal) Other Exoskeletal L5790 Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon Additions fiber or equal) Other Exoskeletal L5795 Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, Additions carbon fiber or equal) Other Lower L2750 Addition to lower extremity orthosis, plating chrome or nickel, per bar Extremity Additions Other Lower L2755 Addition to lower extremity orthosis, high strength, lightweight material, all Extremity hybrid lamination/prepreg composite, per segment, for custom fabricated Additions orthosis only Other Lower L2760 Addition to lower extremity orthosis, extension, per extension, per bar (for Extremity lineal adjustment for growth) Additions Other Lower L2768 Orthotic side bar disconnect device, per bar Extremity Additions Other Lower L2780 Addition to lower extremity orthosis, non-corrosive finish, per bar Extremity Additions Other Lower L2785 Addition to lower extremity orthosis, drop lock retainer, each Extremity Additions Other Lower L2795 Addition to lower extremity orthosis, knee control, full kneecap Extremity Additions Other Lower L2800 Addition to lower extremity orthosis, knee control, knee cap, medial or lateral Extremity pull, for use with custom fabricated orthosis only Additions Other Lower L2810 Addition to lower extremity orthosis, knee control, condylar pad Extremity Additions Other Lower L2820 Addition to lower extremity orthosis, soft interface for molded plastic, below Extremity knee section Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Other Lower L2830 Addition to lower extremity orthosis, soft interface for molded plastic, above Extremity knee section Additions Other Lower L2840 Addition to lower extremity orthosis, tibial length sock, fracture or equal, each Extremity Additions Other Lower L2850 Addition to lower extremity orthosis, femoral length sock, fracture or equal, Extremity each Additions Other Lower L2999 Lower extremity orthoses, not otherwise specified Extremity Additions Other Lower L4350 Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., Extremity pneumatic, gel), prefabricated, off-the-shelf Orthotics Other Lower L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without Extremity interface material, prefabricated item that has been trimmed, bent, molded, Orthotics assembled, or otherwise customized to fit a specific patient by an individual with expertise Other Lower L4361 Walking boot, pneumatic and/or vacuum, with or without joints, with or without Extremity interface material, prefabricated, off-the-shelf Orthotics Other Lower L4370 Pneumatic full leg splint, prefabricated, off-the-shelf Extremity Orthotics Other Lower L4386 Walking boot, non-pneumatic, with or without joints, with or without interface Extremity material, prefabricated item that has been trimmed, bent, molded, assembled, or Orthotics otherwise customized to fit a specific patient by an individual with expertise Other Lower L4387 Walking boot, non-pneumatic, with or without joints, with or without interface Extremity material, prefabricated, off-the-shelf Orthotics Other Lower L4392 Replacement, soft interface material, static afo Extremity Orthotics Other Lower L4394 Replace soft interface material, foot drop splint Extremity Orthotics Other Lower L4396 Static or dynamic ankle foot orthosis, including soft interface material, Extremity adjustable for fit, for positioning, may be used for minimal ambulation, Orthotics prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Other Lower L4397 Static or dynamic ankle foot orthosis, including soft interface material, Extremity adjustable for fit, for positioning, may be used for minimal ambulation, Orthotics prefabricated, off-the-shelf
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Other Lower L4398 Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf Extremity Orthotics Other Lower L4631 Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, Extremity anterior tibial shell, soft interface, custom arch support, plastic or other material, Orthotics includes straps and closures, custom fabricated Other Orthopedic L3215 Orthopedic footwear, ladies shoe, oxford, each Footwear Other Orthopedic L3216 Orthopedic footwear, ladies shoe, depth inlay, each Footwear Other Orthopedic L3217 Orthopedic footwear, ladies shoe, hightop, depth inlay, each Footwear Other Orthopedic L3219 Orthopedic footwear, mens shoe, oxford, each Footwear Other Orthopedic L3221 Orthopedic footwear, mens shoe, depth inlay, each Footwear Other Orthopedic L3222 Orthopedic footwear, mens shoe, hightop, depth inlay, each Footwear Other Orthopedic L3224 Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace Footwear (orthosis) Other Orthopedic L3225 Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace Footwear (orthosis) Other Orthopedic L3230 Orthopedic footwear, custom shoe, depth inlay, each Footwear Other Orthopedic L3251 Foot, shoe molded to patient model, silicone shoe, each Footwear Other Orthopedic L3253 Foot, molded shoe plastazote (or similar) custom fitted, each Footwear Other Orthopedic L3254 Non-standard size or width Footwear Other Orthopedic L3255 Non-standard size or length Footwear Other Orthopedic L3257 Orthopedic footwear, additional charge for split size Footwear Other Orthopedic L3260 Surgical boot/shoe, each Footwear Other Orthopedic L3265 Plastazote sandal, each Footwear Other Orthopedic L3570 Orthopedic shoe addition, special extension to instep (leather with eyelets) Shoe Additions Other Orthopedic L3580 Orthopedic shoe addition, convert instep to velcro closure Shoe Additions Other Orthopedic L3590 Orthopedic shoe addition, convert firm shoe counter to soft counter Shoe Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Other Orthopedic L3595 Orthopedic shoe addition, march bar Shoe Additions Other Scoliosis L1300 Other scoliosis procedure, body jacket molded to patient model and Spinal Orthotics and Procedures Other Scoliosis L1310 Other scoliosis procedure, post-operative body jacket and Spinal Orthotics and Procedures Other Scoliosis L1499 Spinal orthosis, not otherwise specified and Spinal Orthotics and Procedures Other Supplies A4244 Alcohol or peroxide, per pint Including Diabetes Supplies and Contraceptives Other Supplies A4245 Alcohol wipes, per box Including Diabetes Supplies and Contraceptives Other Supplies A4246 Betadine or phisohex solution, per pint Including Diabetes Supplies and Contraceptives Other Supplies A4247 Betadine or iodine swabs/wipes, per box Including Diabetes Supplies and Contraceptives Other Supplies A4250 Urine test or reagent strips or tablets (100 tablets or strips) Including Diabetes Supplies and Contraceptives Other Supplies A4252 Blood ketone test or reagent strip, each Including Diabetes Supplies and Contraceptives
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Other Supplies A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 Including strips Diabetes Supplies and Contraceptives Other Supplies A4255 Platforms for home blood glucose monitor, 50 per box Including Diabetes Supplies and Contraceptives Other Supplies A4256 Normal, low and high calibrator solution / chips Including Diabetes Supplies and Contraceptives Other Supplies A4257 Replacement lens shield cartridge for use with laser skin piercing device, each Including Diabetes Supplies and Contraceptives Other Supplies A4258 Spring-powered device for lancet, each Including Diabetes Supplies and Contraceptives Other Supplies A4259 Lancets, per box of 100 Including Diabetes Supplies and Contraceptives Other Supplies A4265 Paraffin, per pound Including Diabetes Supplies and Contraceptives Other Supplies A4280 Adhesive skin support attachment for use with external breast prosthesis, each Including Diabetes Supplies and Contraceptives Other Supplies A4281 Tubing for breast pump, replacement Including Diabetes Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
and Contraceptives Other Supplies A4282 Adapter for breast pump, replacement Including Diabetes Supplies and Contraceptives Other Supplies A4283 Cap for breast pump bottle, replacement Including Diabetes Supplies and Contraceptives Other Supplies A4284 Breast shield and splash protector for use with breast pump, replacement Including Diabetes Supplies and Contraceptives Other Supplies A4285 Polycarbonate bottle for use with breast pump, replacement Including Diabetes Supplies and Contraceptives Other Supplies A4286 Locking ring for breast pump, replacement Including Diabetes Supplies and Contraceptives Other E1221 Wheelchair with fixed arm, footrests Wheelchairs and Accessories Other E1222 Wheelchair with fixed arm, elevating legrests Wheelchairs and Accessories Other E1223 Wheelchair with detachable arms, footrests Wheelchairs and Accessories Other E1224 Wheelchair with detachable arms, elevating legrests Wheelchairs and Accessories Other E1225 Wheelchair accessory, manual semi-reclining back, (recline greater than 15 Wheelchairs and degrees, but less than 80 degrees), each Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Other E1226 Wheelchair accessory, manual fully reclining back, (recline greater than 80 Wheelchairs and degrees), each Accessories Other E1227 Special height arms for wheelchair Wheelchairs and Accessories Other E1228 Special back height for wheelchair Wheelchairs and Accessories Oxygen Delivery E0424 Stationary compressed gaseous oxygen system, rental; includes container, Systems and contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and Related Supplies tubing Oxygen Delivery E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, Systems and flowmeter, humidifier, cannula or mask, and tubing Related Supplies Oxygen Delivery E0434 Portable liquid oxygen system, rental; includes portable container, supply Systems and reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or Related Supplies mask, and tubing Oxygen Delivery E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, Systems and flowmeter, humidifier, nebulizer, cannula or mask, & tubing Related Supplies Oxygen Delivery E0441 Stationary oxygen contents, gaseous, 1 month's supply = 1 unit Systems and Related Supplies Oxygen Delivery E0442 Stationary oxygen contents, liquid, 1 month's supply = 1 unit Systems and Related Supplies Oxygen Delivery E0443 Portable oxygen contents, gaseous, 1 month's supply = 1 unit Systems and Related Supplies Oxygen Delivery E0444 Portable oxygen contents, liquid, 1 month's supply = 1 unit Systems and Related Supplies Oxygen Delivery E0445 Oximeter device for measuring blood oxygen levels non-invasively Systems and Related Supplies Oxygen Delivery E0457 Chest shell (cuirass) Systems and Related Supplies Oxygen Delivery E0459 Chest wrap Systems and Related Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Oxygen Delivery E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy Systems and tube) Related Supplies Oxygen Delivery E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest Systems and shell) Related Supplies Oxygen Delivery E0467 Home ventilator, multi-function respiratory device, also performs any or all of Systems and the additional functions of oxygen concentration, drug nebulization, aspiration, Related Supplies and cough stimulation, includes all accessories, components and supplies for all functions Oxygen Delivery E0470 Respiratory assist device, bi-level pressure capability, without backup rate Systems and feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent Related Supplies assist device with continuous positive airway pressure device) Oxygen Delivery E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, Systems and used with noninvasive interface, e.g., nasal or facial mask (intermittent assist Related Supplies device with continuous positive airway pressure device) Oxygen Delivery E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, Systems and used with invasive interface, e.g., tracheostomy tube (intermittent assist device Related Supplies with continuous positive airway pressure device) Oxygen Delivery E0480 Percussor, electric or pneumatic, home model Systems and Related Supplies Oxygen Delivery E0482 Cough stimulating device, alternating positive and negative airway pressure Systems and Related Supplies Oxygen Delivery E0483 High frequency chest wall oscillation system, includes all accessories and Systems and supplies, each Related Supplies Oxygen Delivery E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustable or Systems and non-adjustable, prefabricated, includes fitting and adjustment Related Supplies Parenteral B4178 Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit) - Solutions and home mix Supplies Parenteral B4180 Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 Solutions and ml = 1 unit) - home mix Supplies Parenteral B4185 Parenteral nutrition solution, not otherwise specified, 10 grams lipids Solutions and Supplies Parenteral B4189 Parenteral nutrition solution; compounded amino acid and carbohydrates with Solutions and electrolytes, trace elements, and vitamins, including preparation, any strength, Supplies 10 to 51 grams of protein - premix
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Parenteral B4193 Parenteral nutrition solution; compounded amino acid and carbohydrates with Solutions and electrolytes, trace elements, and vitamins, including preparation, any strength, Supplies 52 to 73 grams of protein - premix Parenteral B4197 Parenteral nutrition solution; compounded amino acid and carbohydrates with Solutions and electrolytes, trace elements and vitamins, including preparation, any strength, Supplies 74 to 100 grams of protein - premix Parenteral B4199 Parenteral nutrition solution; compounded amino acid and carbohydrates with Solutions and electrolytes, trace elements and vitamins, including preparation, any strength, Supplies over 100 grams of protein - premix Parenteral B4216 Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes), Solutions and home mix, per day Supplies Parenteral B4220 Parenteral nutrition supply kit; premix, per day Solutions and Supplies Parenteral B4224 Parenteral nutrition administration kit, per day Solutions and Supplies Parenteral B5200 Parenteral nutrition solution compounded amino acid and carbohydrates with Solutions and electrolytes, trace elements, and vitamins, including preparation, any strength, Supplies stress-branch chain amino acids-freamine-hbc-premix Partial Foot L5000 Partial foot, shoe insert with longitudinal arch, toe filler Prosthetics Partial Foot L5010 Partial foot, molded socket, ankle height, with toe filler Prosthetics Partial Foot L5020 Partial foot, molded socket, tibial tubercle height, with toe filler Prosthetics Partial Hand L6000 Partial hand, thumb remaining Prosthetics Partial Hand L6010 Partial hand, little and/or ring finger remaining Prosthetics Partial Hand L6020 Partial hand, no finger remaining Prosthetics Patient Lifts and E0621 Sling or seat, patient lift, canvas or nylon Support Systems Patient Lifts and E0627 Seat lift mechanism, electric, any type Support Systems Patient Lifts and E0630 Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) Support Systems Patient Lifts and E0635 Patient lift, electric with seat or sling Support Systems Patient Lifts and E0637 Combination sit to stand frame/table system, any size including pediatric, with Support Systems seat lift feature, with or without wheels
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Patient Lifts and E0638 Standing frame/table system, one position (e.g., upright, supine or prone Support Systems stander), any size including pediatric, with or without wheels Patient Lifts and E0641 Standing frame/table system, multi-position (e.g., three-way stander), any size Support Systems including pediatric, with or without wheels Pediatric Gait E8000 Gait trainer, pediatric size, posterior support, includes all accessories and Trainers components Pediatric E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system Wheelchairs Pediatric E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system Wheelchairs Pediatric E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating Wheelchairs system Pediatric E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating Wheelchairs system Pediatric E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system Wheelchairs Pediatric E1236 Wheelchair, pediatric size, folding, adjustable, with seating system Wheelchairs Pediatric E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system Wheelchairs Pediatric E1238 Wheelchair, pediatric size, folding, adjustable, without seating system Wheelchairs Pneumatic E0650 Pneumatic compressor, non-segmental home model Compressors and Appliances Pneumatic E0651 Pneumatic compressor, segmental home model without calibrated gradient Compressors and pressure Appliances Pneumatic E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure Compressors and Appliances Pneumatic E0655 Non-segmental pneumatic appliance for use with pneumatic compressor, half Compressors and arm Appliances Pneumatic E0660 Non-segmental pneumatic appliance for use with pneumatic compressor, full Compressors and leg Appliances Pneumatic E0665 Non-segmental pneumatic appliance for use with pneumatic compressor, full Compressors and arm Appliances Pneumatic E0666 Non-segmental pneumatic appliance for use with pneumatic compressor, half Compressors and leg Appliances
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Pneumatic E0667 Segmental pneumatic appliance for use with pneumatic compressor, full leg Compressors and Appliances Pneumatic E0668 Segmental pneumatic appliance for use with pneumatic compressor, full arm Compressors and Appliances Pneumatic E0676 Intermittent limb compression device (includes all accessories), not otherwise Compressors and specified Appliances Power Operated K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and Vehicles including 300 pounds Power Operated K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 Vehicles pounds Power Operated K0802 Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to Vehicles 600 pounds Power Operated K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and Vehicles including 300 pounds Power Operated K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 Vehicles pounds Power Operated K0808 Power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to Vehicles 600 pounds Power E2300 Wheelchair accessory, power seat elevation system, any type Wheelchair Accessories Power E2301 Wheelchair accessory, power standing system, any type Wheelchair Accessories Power E2310 Power wheelchair accessory, electronic connection between wheelchair Wheelchair controller and one power seating system motor, including all related electronics, Accessories indicator feature, mechanical function selection switch, and fixed mounting hardware Power E2311 Power wheelchair accessory, electronic connection between wheelchair Wheelchair controller and two or more power seating system motors, including all related Accessories electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware Power E2312 Power wheelchair accessory, hand or chin control interface, mini-proportional Wheelchair remote joystick, proportional, including fixed mounting hardware Accessories Power E2313 Power wheelchair accessory, harness for upgrade to expandable controller, Wheelchair including all fasteners, connectors and mounting hardware, each Accessories Power E2321 Power wheelchair accessory, hand control interface, remote joystick, Wheelchair nonproportional, including all related electronics, mechanical stop switch, and Accessories fixed mounting hardware
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Power E2322 Power wheelchair accessory, hand control interface, multiple mechanical Wheelchair switches, nonproportional, including all related electronics, mechanical stop Accessories switch, and fixed mounting hardware Power E2323 Power wheelchair accessory, specialty joystick handle for hand control Wheelchair interface, prefabricated Accessories Power E2324 Power wheelchair accessory, chin cup for chin control interface Wheelchair Accessories Power E2325 Power wheelchair accessory, sip and puff interface, nonproportional, including Wheelchair all related electronics, mechanical stop switch, and manual swingaway Accessories mounting hardware Power E2326 Power wheelchair accessory, breath tube kit for sip and puff interface Wheelchair Accessories Power E2327 Power wheelchair accessory, head control interface, mechanical, proportional, Wheelchair including all related electronics, mechanical direction change switch, and fixed Accessories mounting hardware Power E2328 Power wheelchair accessory, head control or extremity control interface, Wheelchair electronic, proportional, including all related electronics and fixed mounting Accessories hardware Power E2329 Power wheelchair accessory, head control interface, contact switch mechanism, Wheelchair nonproportional, including all related electronics, mechanical stop switch, Accessories mechanical direction change switch, head array, and fixed mounting hardware Power E2330 Power wheelchair accessory, head control interface, proximity switch Wheelchair mechanism, nonproportional, including all related electronics, mechanical stop Accessories switch, mechanical direction change switch, head array, and fixed mounting hardware Power E2331 Power wheelchair accessory, attendant control, proportional, including all Wheelchair related electronics and fixed mounting hardware Accessories Power E2340 Power wheelchair accessory, nonstandard seat frame width, 20-23 inches Wheelchair Accessories Power E2341 Power wheelchair accessory, nonstandard seat frame width, 24-27 inches Wheelchair Accessories Power E2342 Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches Wheelchair Accessories Power E2343 Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches Wheelchair Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Power E2351 Power wheelchair accessory, electronic interface to operate speech generating Wheelchair device using power wheelchair control interface Accessories Power E2359 Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g., gel Wheelchair cell, absorbed glassmat) Accessories Power E2360 Power wheelchair accessory, 22nf non-sealed lead acid battery, each Wheelchair Accessories Power E2361 Power wheelchair accessory, 22nf sealed lead acid battery, each, (e.g., gel cell, Wheelchair absorbed glassmat) Accessories Power E2362 Power wheelchair accessory, group 24 non-sealed lead acid battery, each Wheelchair Accessories Power E2363 Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel Wheelchair cell, absorbed glassmat) Accessories Power E2364 Power wheelchair accessory, u-1 non-sealed lead acid battery, each Wheelchair Accessories Power E2365 Power wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, Wheelchair absorbed glassmat) Accessories Power E2366 Power wheelchair accessory, battery charger, single mode, for use with only one Wheelchair battery type, sealed or non-sealed, each Accessories Power E2367 Power wheelchair accessory, battery charger, dual mode, for use with either Wheelchair battery type, sealed or non-sealed, each Accessories Power E2368 Power wheelchair component, drive wheel motor, replacement only Wheelchair Accessories Power E2369 Power wheelchair component, drive wheel gear box, replacement only Wheelchair Accessories Power E2370 Power wheelchair component, integrated drive wheel motor and gear box Wheelchair combination, replacement only Accessories Power E2371 Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, Wheelchair absorbed glassmat), each Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Power E2373 Power wheelchair accessory, hand or chin control interface, compact remote Wheelchair joystick, proportional, including fixed mounting hardware Accessories Power E2374 Power wheelchair accessory, hand or chin control interface, standard remote Wheelchair joystick (not including controller), proportional, including all related electronics Accessories and fixed mounting hardware, replacement only Power E2375 Power wheelchair accessory, non-expandable controller, including all related Wheelchair electronics and mounting hardware, replacement only Accessories Power E2376 Power wheelchair accessory, expandable controller, including all related Wheelchair electronics and mounting hardware, replacement only Accessories Power E2377 Power wheelchair accessory, expandable controller, including all related Wheelchair electronics and mounting hardware, upgrade provided at initial issue Accessories Power E2378 Power wheelchair component, actuator, replacement only Wheelchair Accessories Power E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement Wheelchair only, each Accessories Power E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, Wheelchair replacement only, each Accessories Power E2383 Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), Wheelchair any type, any size, replacement only, each Accessories Power E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only, Wheelchair each Accessories Power E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, Wheelchair replacement only, each Accessories Power E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement Wheelchair only, each Accessories Power E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, Wheelchair each Accessories Power E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, Wheelchair each Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Power E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each Wheelchair Accessories Power E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, Wheelchair replacement only, each Accessories Power E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any Wheelchair size, replacement only, each Accessories Power E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated Wheelchair wheel, any size, replacement only, each Accessories Power E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement Wheelchair only, each Accessories Power E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement Wheelchair only, each Accessories Power E2396 Power wheelchair accessory, caster fork, any size, replacement only, each Wheelchair Accessories Preparatory L6580 Preparatory, wrist disarticulation or below elbow, single wall plastic socket, Prosthetic, Upper friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Limbs bowden cable control, usmc or equal pylon, no cover, molded to patient model Preparatory L6582 Preparatory, wrist disarticulation or below elbow, single wall socket, friction Prosthetic, Upper wrist, flexible elbow hinges, figure of eight harness, humeral cuff, bowden Limbs cable control, usmc or equal pylon, no cover, direct formed Preparatory L6584 Preparatory, elbow disarticulation or above elbow, single wall plastic socket, Prosthetic, Upper friction wrist, locking elbow, figure of eight harness, fair lead cable control, Limbs usmc or equal pylon, no cover, molded to patient model Preparatory L6586 Preparatory, elbow disarticulation or above elbow, single wall socket, friction Prosthetic, Upper wrist, locking elbow, figure of eight harness, fair lead cable control, usmc or Limbs equal pylon, no cover, direct formed Preparatory L6588 Preparatory, shoulder disarticulation or interscapular thoracic, single wall Prosthetic, Upper plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead Limbs cable control, usmc or equal pylon, no cover, molded to patient model Preparatory L6590 Preparatory, shoulder disarticulation or interscapular thoracic, single wall Prosthetic, Upper socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable Limbs control, usmc or equal pylon, no cover, direct formed Pressure E0181 Powered pressure reducing mattress overlay/pad, alternating, with pump, Mattresses, Pads, includes heavy duty and Other Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Pressure E0184 Dry pressure mattress Mattresses, Pads, and Other Supplies Pressure E0185 Gel or gel-like pressure pad for mattress, standard mattress length and width Mattresses, Pads, and Other Supplies Pressure E0186 Air pressure mattress Mattresses, Pads, and Other Supplies Pressure E0187 Water pressure mattress Mattresses, Pads, and Other Supplies Pressure E0189 Lambswool sheepskin pad, any size Mattresses, Pads, and Other Supplies Pressure E0190 Positioning cushion/pillow/wedge, any shape or size, includes all components Mattresses, Pads, and accessories and Other Supplies Pressure E0191 Heel or elbow protector, each Mattresses, Pads, and Other Supplies Pressure E0194 Air fluidized bed Mattresses, Pads, and Other Supplies Pressure E0196 Gel pressure mattress Mattresses, Pads, and Other Supplies Pressure E0197 Air pressure pad for mattress, standard mattress length and width Mattresses, Pads, and Other Supplies Pressure E0198 Water pressure pad for mattress, standard mattress length and width Mattresses, Pads, and Other Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Pressure E0199 Dry pressure pad for mattress, standard mattress length and width Mattresses, Pads, and Other Supplies Prosthetic Fitting, L5400 Immediate post surgical or early fitting, application of initial rigid dressing, Immediate including fitting, alignment, suspension, and one cast change, below knee Postsurgical or Early, Lower Limbs Prosthetic Fitting, L5410 Immediate post surgical or early fitting, application of initial rigid dressing, Immediate including fitting, alignment and suspension, below knee, each additional cast Postsurgical or change and realignment Early, Lower Limbs Prosthetic Fitting, L5420 Immediate post surgical or early fitting, application of initial rigid dressing, Immediate including fitting, alignment and suspension and one cast change 'ak' or knee Postsurgical or disarticulation Early, Lower Limbs Prosthetic Fitting, L5430 Immediate post surgical or early fitting, application of initial rigid dressing, incl. Immediate fitting, alignment and supension, 'ak' or knee disarticulation, each additional Postsurgical or cast change and realignment Early, Lower Limbs Prosthetic Fitting, L5450 Immediate post surgical or early fitting, application of non-weight bearing rigid Immediate dressing, below knee Postsurgical or Early, Lower Limbs Prosthetic Fitting, L5460 Immediate post surgical or early fitting, application of non-weight bearing rigid Immediate dressing, above knee Postsurgical or Early, Lower Limbs Prosthetic Fitting, L6380 Immediate post surgical or early fitting, application of initial rigid dressing, Immediate including fitting alignment and suspension of components, and one cast change, Postsurgical or wrist disarticulation or below elbow Early, Upper Limbs Prosthetic Fitting, L6382 Immediate post surgical or early fitting, application of initial rigid dressing Immediate including fitting alignment and suspension of components, and one cast change, Postsurgical or elbow disarticulation or above elbow Early, Upper Limbs
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Prosthetic Fitting, L6384 Immediate post surgical or early fitting, application of initial rigid dressing Immediate including fitting alignment and suspension of components, and one cast change, Postsurgical or shoulder disarticulation or interscapular thoracic Early, Upper Limbs Prosthetic Fitting, L6386 Immediate post surgical or early fitting, each additional cast change and Immediate realignment Postsurgical or Early, Upper Limbs Prosthetic Fitting, L6388 Immediate post surgical or early fitting, application of rigid dressing only Immediate Postsurgical or Early, Upper Limbs Prosthetic Repair L7510 Repair of prosthetic device, repair or replace minor parts Prosthetic Repair L7520 Repair prosthetic device, labor component, per 15 minutes Prosthetic L8400 Prosthetic sheath, below knee, each Sheaths, Socks, and Shrinkers Prosthetic L8410 Prosthetic sheath, above knee, each Sheaths, Socks, and Shrinkers Prosthetic L8415 Prosthetic sheath, upper limb, each Sheaths, Socks, and Shrinkers Prosthetic L8417 Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, Sheaths, Socks, each and Shrinkers Prosthetic L8420 Prosthetic sock, multiple ply, below knee, each Sheaths, Socks, and Shrinkers Prosthetic L8430 Prosthetic sock, multiple ply, above knee, each Sheaths, Socks, and Shrinkers Prosthetic L8435 Prosthetic sock, multiple ply, upper limb, each Sheaths, Socks, and Shrinkers Prosthetic L8440 Prosthetic shrinker, below knee, each Sheaths, Socks, and Shrinkers Prosthetic L8460 Prosthetic shrinker, above knee, each Sheaths, Socks, and Shrinkers
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Prosthetic L8465 Prosthetic shrinker, upper limb, each Sheaths, Socks, and Shrinkers Prosthetic L8470 Prosthetic sock, single ply, fitting, below knee, each Sheaths, Socks, and Shrinkers Prosthetic L8480 Prosthetic sock, single ply, fitting, above knee, each Sheaths, Socks, and Shrinkers Prosthetic L8485 Prosthetic sock, single ply, fitting, upper limb, each Sheaths, Socks, and Shrinkers Repair of V5336 Repair/modification of augmentative communicative system or device augmentative (excludes adaptive hearing aid) communicative system Replacement A4233 Replacement battery, alkaline (other than j cell), for use with medically Batteries necessary home blood glucose monitor owned by patient, each Replacement A4235 Replacement battery, lithium, for use with medically necessary home blood Batteries glucose monitor owned by patient, each Replacement A4630 Replacement batteries, medically necessary, transcutaneous electrical Parts stimulator, owned by patient Replacement A4635 Underarm pad, crutch, replacement, each Parts Replacement A4636 Replacement, handgrip, cane, crutch, or walker, each Parts Replacement A4637 Replacement, tip, cane, crutch, walker, each. Parts Replacement A4640 Replacement pad for use with medically necessary alternating pressure pad Parts owned by patient Replacement L5700 Replacement, socket, below knee, molded to patient model Sockets Replacement L5701 Replacement, socket, above knee/knee disarticulation, including attachment Sockets plate, molded to patient model Replacement L5702 Replacement, socket, hip disarticulation, including hip joint, molded to patient Sockets model Replacement L5703 Ankle, symes, molded to patient model, socket without solid ankle cushion heel Sockets (sach) foot, replacement only Repositioning L3100 Hallus-valgus night dynamic splint, prefabricated, off-the-shelf Foot Orthotics Repositioning L3140 Foot, abduction rotation bar, including shoes Foot Orthotics Repositioning L3150 Foot, abduction rotation bar, without shoes Foot Orthotics
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Repositioning L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each Foot Orthotics Respiratory A4611 Battery, heavy duty; replacement for patient owned ventilator Supplies and Equipment Respiratory A4612 Battery cables; replacement for patient-owned ventilator Supplies and Equipment Respiratory A4613 Battery charger; replacement for patient-owned ventilator Supplies and Equipment Respiratory A4614 Peak expiratory flow rate meter, hand held Supplies and Equipment Respiratory A4615 Cannula, nasal Supplies and Equipment Respiratory A4616 Tubing (oxygen), per foot Supplies and Equipment Respiratory A4618 Breathing circuits Supplies and Equipment Respiratory A4620 Variable concentration mask Supplies and Equipment Respiratory A4623 Tracheostomy, inner cannula Supplies and Equipment Respiratory A4624 Tracheal suction catheter, any type other than closed system, each Supplies and Equipment Respiratory A4625 Tracheostomy care kit for new tracheostomy Supplies and Equipment Respiratory A4626 Tracheostomy cleaning brush, each Supplies and Equipment Respiratory A4627 Spacer, bag or reservoir, with or without mask, for use with metered dose Supplies and inhaler Equipment Respiratory A4628 Oropharyngeal suction catheter, each Supplies and Equipment
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Respiratory A4629 Tracheostomy care kit for established tracheostomy Supplies and Equipment Sacral Orthotics L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf Sacral Orthotics L0622 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated Sacral Orthotics L0623 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf Sacral Orthotics L0624 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated Safety Devices E0705 Transfer device, any type, each Scoliosis Orthotic L1000 Cervical-thoracic-lumbar-sacral orthosis (ctlso) (milwaukee), inclusive of Devices furnishing initial orthosis, including model Scoliosis Orthotic L1005 Tension based scoliosis orthosis and accessory pads, includes fitting and Devices adjustment Scoliosis Orthotic L1010 Addition to cervical-thoracic-lumbar-sacral orthosis (ctlso) or scoliosis orthosis, Devices axilla sling Scoliosis Orthotic L1020 Addition to ctlso or scoliosis orthosis, kyphosis pad Devices Scoliosis Orthotic L1025 Addition to ctlso or scoliosis orthosis, kyphosis pad, floating Devices Scoliosis Orthotic L1030 Addition to ctlso or scoliosis orthosis, lumbar bolster pad Devices Scoliosis Orthotic L1040 Addition to ctlso or scoliosis orthosis, lumbar or lumbar rib pad Devices Scoliosis Orthotic L1050 Addition to ctlso or scoliosis orthosis, sternal pad Devices Scoliosis Orthotic L1060 Addition to ctlso or scoliosis orthosis, thoracic pad Devices Scoliosis Orthotic L1070 Addition to ctlso or scoliosis orthosis, trapezius sling Devices Scoliosis Orthotic L1080 Addition to ctlso or scoliosis orthosis, outrigger Devices Scoliosis Orthotic L1085 Addition to ctlso or scoliosis orthosis, outrigger, bilateral with vertical Devices extensions Scoliosis Orthotic L1090 Addition to ctlso or scoliosis orthosis, lumbar sling Devices
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Scoliosis Orthotic L1100 Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather Devices Scoliosis Orthotic L1110 Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather, molded to Devices patient model Scoliosis Orthotic L1120 Addition to ctlso, scoliosis orthosis, cover for upright, each Devices Semi-reclining E1100 Semi-reclining wheelchair, fixed full length arms, swing away detachable Wheelchairs elevating leg rests Semi-reclining E1110 Semi-reclining wheelchair, detachable arms (desk or full length) elevating leg Wheelchairs rest Shoe Heels L3430 Heel, counter, plastic reinforced Shoe Heels L3440 Heel, counter, leather reinforced Shoe Heels L3450 Heel, sach cushion type Shoe Heels L3460 Heel, new rubber, standard Shoe Heels L3465 Heel, thomas with wedge Shoe Heels L3470 Heel, thomas extended to ball Shoe Heels L3480 Heel, pad and depression for spur Shoe Lifts L3300 Lift, elevation, heel, tapered to metatarsals, per inch Shoe Lifts L3310 Lift, elevation, heel and sole, neoprene, per inch Shoe Lifts L3320 Lift, elevation, heel and sole, cork, per inch Shoe Lifts L3330 Lift, elevation, metal extension (skate) Shoe Lifts L3332 Lift, elevation, inside shoe, tapered, up to one-half inch Shoe Lifts L3334 Lift, elevation, heel, per inch Shoe Wedges L3340 Heel wedge, sach Shoe Wedges L3350 Heel wedge Shoe Wedges L3360 Sole wedge, outside sole Shoe Wedges L3370 Sole wedge, between sole Shoe Wedges L3380 Clubfoot wedge Shoe Wedges L3390 Outflare wedge Shoe Wedges L3400 Metatarsal bar wedge, rocker Shoe Wedges L3410 Metatarsal bar wedge, between sole Shoe Wedges L3420 Full sole and heel wedge, between sole Shoulder L6300 Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, Disarticulation, internal locking elbow, forearm Arm and Hand Prosthetics Shoulder L6310 Shoulder disarticulation, passive restoration (complete prosthesis) Disarticulation, Arm and Hand Prosthetics Shoulder L6320 Shoulder disarticulation, passive restoration (shoulder cap only) Disarticulation, Arm and Hand Prosthetics
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Shoulder L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off- Orthotics the-shelf Shoulder L3660 Shoulder orthosis, figure of eight design abduction restrainer, canvas and Orthotics webbing, prefabricated, off-the-shelf Shoulder L3670 Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, Orthotics off-the-shelf Shoulder L3675 Shoulder orthosis, vest type abduction restrainer, canvas webbing type or equal, Orthotics prefabricated, off-the-shelf Shoulder L3677 Shoulder orthosis, shoulder joint design, without joints, may include soft Orthotics interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Shoulder-elbow- L3960 Shoulder elbow wrist hand orthosis, abduction positioning, airplane design, wrist-hand prefabricated, includes fitting and adjustment Orthotics Shoulder-elbow- L3962 Shoulder elbow wrist hand orthosis, abduction positioning, erb's palsey design, wrist-hand prefabricated, includes fitting and adjustment Orthotics Sitz E0160 Sitz type bath or equipment, portable, used with or without commode Bath/Equipment Sitz E0161 Sitz type bath or equipment, portable, used with or without commode, with Bath/Equipment faucet attachment/s Socket Insert, L5654 Addition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, Suspensions, and plastazote or equal) Other Prosthetic Additions Socket Insert, L5655 Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, Suspensions, and plastazote or equal) Other Prosthetic Additions Socket Insert, L5656 Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, Suspensions, and aliplast, plastazote or equal) Other Prosthetic Additions Socket Insert, L5658 Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, Suspensions, and plastazote or equal) Other Prosthetic Additions Socket Insert, L5661 Addition to lower extremity, socket insert, multi-durometer symes Suspensions, and Other Prosthetic Additions Socket Insert, L5665 Addition to lower extremity, socket insert, multi-durometer, below knee Suspensions, and
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Other Prosthetic Additions Socket Insert, L5666 Addition to lower extremity, below knee, cuff suspension Suspensions, and Other Prosthetic Additions Socket Insert, L5668 Addition to lower extremity, below knee, molded distal cushion Suspensions, and Other Prosthetic Additions Socket Insert, L5670 Addition to lower extremity, below knee, molded supracondylar suspension Suspensions, and ('pts' or similar) Other Prosthetic Additions Socket Insert, L5671 Addition to lower extremity, below knee / above knee suspension locking Suspensions, and mechanism (shuttle, lanyard or equal), excludes socket insert Other Prosthetic Additions Socket Insert, L5672 Addition to lower extremity, below knee, removable medial brim suspension Suspensions, and Other Prosthetic Additions Socket Insert, L5673 Addition to lower extremity, below knee/above knee, custom fabricated from Suspensions, and existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, Other Prosthetic for use with locking mechanism Additions Socket Insert, L5676 Additions to lower extremity, below knee, knee joints, single axis, pair Suspensions, and Other Prosthetic Additions Socket Insert, L5677 Additions to lower extremity, below knee, knee joints, polycentric, pair Suspensions, and Other Prosthetic Additions Socket Insert, L5678 Additions to lower extremity, below knee, joint covers, pair Suspensions, and Other Prosthetic Additions Socket Insert, L5679 Addition to lower extremity, below knee/above knee, custom fabricated from Suspensions, and existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, Other Prosthetic not for use with locking mechanism Additions Socket Insert, L5680 Addition to lower extremity, below knee, thigh lacer, nonmolded Suspensions, and
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Other Prosthetic Additions Socket Insert, L5681 Addition to lower extremity, below knee/above knee, custom fabricated socket Suspensions, and insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or Other Prosthetic equal, for use with or without locking mechanism, initial only (for other than Additions initial, use code l5673 or l5679) Socket Insert, L5682 Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded Suspensions, and Other Prosthetic Additions Socket Insert, L5684 Addition to lower extremity, below knee, fork strap Suspensions, and Other Prosthetic Additions Socket Insert, L5685 Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, Suspensions, and with or without valve, any material, each Other Prosthetic Additions Socket Insert, L5686 Addition to lower extremity, below knee, back check (extension control) Suspensions, and Other Prosthetic Additions Socket Insert, L5688 Addition to lower extremity, below knee, waist belt, webbing Suspensions, and Other Prosthetic Additions Socket Insert, L5690 Addition to lower extremity, below knee, waist belt, padded and lined Suspensions, and Other Prosthetic Additions Socket Insert, L5692 Addition to lower extremity, above knee, pelvic control belt, light Suspensions, and Other Prosthetic Additions Socket Insert, L5694 Addition to lower extremity, above knee, pelvic control belt, padded and lined Suspensions, and Other Prosthetic Additions Socket Insert, L5695 Addition to lower extremity, above knee, pelvic control, sleeve suspension, Suspensions, and neoprene or equal, each Other Prosthetic Additions Socket Insert, L5696 Addition to lower extremity, above knee or knee disarticulation, pelvic joint Suspensions, and
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Other Prosthetic Additions Socket Insert, L5697 Addition to lower extremity, above knee or knee disarticulation, pelvic band Suspensions, and Other Prosthetic Additions Socket Insert, L5698 Addition to lower extremity, above knee or knee disarticulation, silesian Suspensions, and bandage Other Prosthetic Additions Socket Insert, L5699 All lower extremity prostheses, shoulder harness Suspensions, and Other Prosthetic Additions Speech E2500 Speech generating device, digitized speech, using pre-recorded messages, less Generating than or equal to 8 minutes recording time Devices, Software, and Accessories Speech E2502 Speech generating device, digitized speech, using pre-recorded messages, Generating greater than 8 minutes but less than or equal to 20 minutes recording time Devices, Software, and Accessories Speech E2504 Speech generating device, digitized speech, using pre-recorded messages, Generating greater than 20 minutes but less than or equal to 40 minutes recording time Devices, Software, and Accessories Speech E2506 Speech generating device, digitized speech, using pre-recorded messages, Generating greater than 40 minutes recording time Devices, Software, and Accessories Speech E2508 Speech generating device, synthesized speech, requiring message formulation Generating by spelling and access by physical contact with the device Devices, Software, and Accessories Speech E2510 Speech generating device, synthesized speech, permitting multiple methods of Generating message formulation and multiple methods of device access Devices, Software, and Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Speech E2511 Speech generating software program, for personal computer or personal digital Generating assistant Devices, Software, and Accessories Speech E2512 Accessory for speech generating device, mounting system Generating Devices, Software, and Accessories Speech E2599 Accessory for speech generating device, not otherwise classified Generating Devices, Software, and Accessories Standard E1130 Standard wheelchair, fixed full length arms, fixed or swing away detachable Wheelchairs footrests Standard E1140 Wheelchair, detachable arms, desk or full length, swing away detachable Wheelchairs footrests Standard E1150 Wheelchair, detachable arms, desk or full length swing away detachable Wheelchairs elevating legrests Standard E1160 Wheelchair, fixed full length arms, swing away detachable elevating legrests Wheelchairs Standard E1161 Manual adult size wheelchair, includes tilt in space Wheelchairs Stimulation E0720 Transcutaneous electrical nerve stimulation (tens) device, two lead, localized Devices stimulation Stimulation E0730 Transcutaneous electrical nerve stimulation (tens) device, four or more leads, Devices for multiple nerve stimulation Stimulation E0731 Form fitting conductive garment for delivery of tens or nmes (with conductive Devices fibers separated from the patient's skin by layers of fabric) Stimulation E0744 Neuromuscular stimulator for scoliosis Devices Stimulation E0745 Neuromuscular stimulator, electronic shock unit Devices Stimulation E0747 Osteogenesis stimulator, electrical, non-invasive, other than spinal applications Devices Stimulation E0748 Osteogenesis stimulator, electrical, non-invasive, spinal applications Devices Stimulation E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive Devices Stimulation E0766 Electrical stimulation device used for cancer treatment, includes all accessories, Devices any type
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Supply, L5530 Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no Preparatory cover, sach foot, thermoplastic or equal, molded to model Prosthesis Supply, L5535 Preparatory, below knee 'ptb' type socket, non-alignable system, no cover, sach Preparatory foot, prefabricated, adjustable open end socket Prosthesis Supply, L5540 Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no Preparatory cover, sach foot, laminated socket, molded to model Prosthesis Supply, L5560 Preparatory, above knee- knee disarticulation, ischial level socket, non- Preparatory alignable system, pylon, no cover, sach foot, plaster socket, molded to model Prosthesis Supply, L5580 Preparatory, above knee - knee disarticulation ischial level socket, non- Preparatory alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to Prosthesis model Supply, L5585 Preparatory, above knee - knee disarticulation, ischial level socket, non- Preparatory alignable system, pylon, no cover, sach foot, prefabricated adjustable open end Prosthesis socket Supply, L5590 Preparatory, above knee - knee disarticulation ischial level socket, non- Preparatory alignable system, pylon no cover, sach foot, laminated socket, molded to model Prosthesis Supply, L5595 Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, Preparatory thermoplastic or equal, molded to patient model Prosthesis Supply, L5600 Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, Preparatory laminated socket, molded to patient model Prosthesis Surgical Boots L3208 Surgical boot, each, infant Surgical Boots L3209 Surgical boot, each, child Surgical Boots L3211 Surgical boot, each, junior Terminal Devices L6703 Terminal device, passive hand/mitt, any material, any size and Additions Terminal Devices L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, and Additions lined or unlined Terminal Devices L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, and Additions lined or unlined Terminal Devices L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size and Additions Terminal Devices L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size and Additions Terminal Devices L6711 Terminal device, hook, mechanical, voluntary opening, any material, any size, and Additions lined or unlined, pediatric Terminal Devices L6714 Terminal device, hand, mechanical, voluntary closing, any material, any size, and Additions pediatric
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Terminal Devices L6805 Addition to terminal device, modifier wrist unit and Additions Terminal Devices L6810 Addition to terminal device, precision pinch device and Additions Terminal Devices L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal and Additions device Terminal Devices L6882 Microprocessor control feature, addition to upper limb prosthetic terminal and Additions device Test Socket L5618 Addition to lower extremity, test socket, symes Prosthetic Additions, Lower Extremities Test Socket L5620 Addition to lower extremity, test socket, below knee Prosthetic Additions, Lower Extremities Test Socket L5622 Addition to lower extremity, test socket, knee disarticulation Prosthetic Additions, Lower Extremities Test Socket L5624 Addition to lower extremity, test socket, above knee Prosthetic Additions, Lower Extremities Test Socket L5626 Addition to lower extremity, test socket, hip disarticulation Prosthetic Additions, Lower Extremities Test Socket L5628 Addition to lower extremity, test socket, hemipelvectomy Prosthetic Additions, Lower Extremities Thoracic Rib L0220 Thoracic, rib belt, custom fabricated Belts Thoracic-lumbar- L0450 Tlso, flexible, provides trunk support, upper thoracic region, produces sacral (TLSO) intracavitary pressure to reduce load on the intervertebral disks with rigid stays Orthotics or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf Thoracic-lumbar- L0452 Tlso, flexible, provides trunk support, upper thoracic region, produces sacral (TLSO) intracavitary pressure to reduce load on the intervertebral disks with rigid stays Orthotics or panel(s), includes shoulder straps and closures, custom fabricated Thoracic-lumbar- L0454 Tlso flexible, provides trunk support, extends from sacrococcygeal junction to sacral (TLSO) above t-9 vertebra, restricts gross trunk motion in the sagittal plane, produces Orthotics intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated item that has
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Thoracic-lumbar- L0456 Tlso, flexible, provides trunk support, thoracic region, rigid posterior panel and sacral (TLSO) soft anterior apron, extends from the sacrococcygeal junction and terminates Orthotics just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Thoracic-lumbar- L0458 Tlso, triplanar control, modular segmented spinal system, two rigid plastic sacral (TLSO) shells, posterior extends from the sacrococcygeal junction and terminates just Orthotics inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Thoracic-lumbar- L0460 Tlso, triplanar control, modular segmented spinal system, two rigid plastic sacral (TLSO) shells, posterior extends from the sacrococcygeal junction and terminates just Orthotics inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Thoracic-lumbar- L0462 Tlso, triplanar control, modular segmented spinal system, three rigid plastic sacral (TLSO) shells, posterior extends from the sacrococcygeal junction and terminates just Orthotics inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Thoracic-lumbar- L0464 Tlso, triplanar control, modular segmented spinal system, four rigid plastic sacral (TLSO) shells, posterior extends from sacrococcygeal junction and terminates just Orthotics inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Thoracic-lumbar- L0466 Tlso, sagittal control, rigid posterior frame and flexible soft anterior apron with sacral (TLSO) straps, closures and padding, restricts gross trunk motion in sagittal plane, Orthotics produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Thoracic-lumbar- L0468 Tlso, sagittal-coronal control, rigid posterior frame and flexible soft anterior sacral (TLSO) apron with straps, closures and padding, extends from sacrococcygeal junction Orthotics over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Thoracic-lumbar- L0470 Tlso, triplanar control, rigid posterior frame and flexible soft anterior apron with sacral (TLSO) straps, closures and padding, extends from sacrococcygeal junction to scapula, Orthotics lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment Thoracic-lumbar- L0472 Tlso, triplanar control, hyperextension, rigid anterior and lateral frame extends sacral (TLSO) from symphysis pubis to sternal notch with two anterior components (one pubic Orthotics and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment Thoracic-lumbar- L0480 Tlso, triplanar control, one piece rigid plastic shell without interface liner, with sacral (TLSO) multiple straps and closures, posterior extends from sacrococcygeal junction Orthotics and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated Thoracic-lumbar- L0482 Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple sacral (TLSO) straps and closures, posterior extends from sacrococcygeal junction and Orthotics terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated Thoracic-lumbar- L0484 Tlso, triplanar control, two piece rigid plastic shell without interface liner, with sacral (TLSO) multiple straps and closures, posterior extends from sacrococcygeal junction Orthotics and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated Thoracic-lumbar- L0486 Tlso, triplanar control, two piece rigid plastic shell with interface liner, multiple sacral (TLSO) straps and closures, posterior extends from sacrococcygeal junction and Orthotics terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Thoracic-lumbar- L0488 Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple sacral (TLSO) straps and closures, posterior extends from sacrococcygeal junction and Orthotics terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment Thoracic-lumbar- L0490 Tlso, sagittal-coronal control, one piece rigid plastic shell, with overlapping sacral (TLSO) reinforced anterior, with multiple straps and closures, posterior extends from Orthotics sacrococcygeal junction and terminates at or before the t-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment Thoracic-lumbar- L0491 Tlso, sagittal-coronal control, modular segmented spinal system, two rigid sacral (TLSO) plastic shells, posterior extends from the sacrococcygeal junction and terminates Orthotics just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment Tracheostoma A7501 Tracheostoma valve, including diaphragm, each Supplies Tracheostoma A7502 Replacement diaphragm/faceplate for tracheostoma valve, each Supplies Tracheostoma A7503 Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture Supplies exchange system, each Tracheostoma A7504 Filter for use in a tracheostoma heat and moisture exchange system, each Supplies Tracheostoma A7505 Housing, reusable without adhesive, for use in a heat and moisture exchange Supplies system and/or with a tracheostoma valve, each Tracheostoma A7506 Adhesive disc for use in a heat and moisture exchange system and/or with Supplies tracheostoma valve, any type each Tracheostoma A7507 Filter holder and integrated filter without adhesive, for use in a tracheostoma Supplies heat and moisture exchange system, each Tracheostoma A7508 Housing and integrated adhesive, for use in a tracheostoma heat and moisture Supplies exchange system and/or with a tracheostoma valve, each Tracheostoma A7509 Filter holder and integrated filter housing, and adhesive, for use as a Supplies tracheostoma heat and moisture exchange system, each Tracheostoma A7520 Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (pvc), silicone Supplies or equal, each Tracheostoma A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (pvc), silicone or Supplies equal, each Tracheostoma A7522 Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and Supplies reusable), each
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Tracheostoma A7525 Tracheostomy mask, each Supplies Tracheostoma A7526 Tracheostomy tube collar/holder, each Supplies Traction and E0840 Traction frame, attached to headboard, cervical traction Other Orthopedic Devices Traction and E0850 Traction stand, free standing, cervical traction Other Orthopedic Devices Traction and E0860 Traction equipment, overdoor, cervical Other Orthopedic Devices Traction and E0870 Traction frame, attached to footboard, extremity traction, (e.g., buck's) Other Orthopedic Devices Traction and E0880 Traction stand, free standing, extremity traction Other Orthopedic Devices Traction and E0890 Traction frame, attached to footboard, pelvic traction Other Orthopedic Devices Traction and E0900 Traction stand, free standing, pelvic traction, (e.g., buck's) Other Orthopedic Devices Traction and E0910 Trapeze bars, a/k/a patient helper, attached to bed, with grab bar Other Orthopedic Devices Traction and E0911 Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, Other Orthopedic attached to bed, with grab bar Devices Traction and E0912 Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, Other Orthopedic free standing, complete with grab bar Devices Traction and E0920 Fracture frame, attached to bed, includes weights Other Orthopedic Devices Traction and E0930 Fracture frame, free standing, includes weights Other Orthopedic Devices Traction and E0935 Continuous passive motion exercise device for use on knee only Other Orthopedic Devices
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Traction and E0940 Trapeze bar, free standing, complete with grab bar Other Orthopedic Devices Traction and E0942 Cervical head harness/halter Other Orthopedic Devices Traction and E0944 Pelvic belt/harness/boot Other Orthopedic Devices Traction and E0945 Extremity belt/harness Other Orthopedic Devices Traction and E0947 Fracture frame, attachments for complex pelvic traction Other Orthopedic Devices Traction and E0948 Fracture frame, attachments for complex cervical traction Other Orthopedic Devices Transport Chairs E1038 Transport chair, adult size, patient weight capacity up to and including 300 pounds Transport Chairs E1039 Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds Unlisted L8499 Unlisted procedure for miscellaneous prosthetic services Prosthetic Procedures Upper Extremity L6600 Upper extremity additions, polycentric hinge, pair Prosthetic Additions Upper Extremity L6605 Upper extremity additions, single pivot hinge, pair Prosthetic Additions Upper Extremity L6610 Upper extremity additions, flexible metal hinge, pair Prosthetic Additions Upper Extremity L6615 Upper extremity addition, disconnect locking wrist unit Prosthetic Additions Upper Extremity L6616 Upper extremity addition, additional disconnect insert for locking wrist unit, Prosthetic each Additions Upper Extremity L6620 Upper extremity addition, flexion/extension wrist unit, with or without friction Prosthetic Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Upper Extremity L6624 Upper extremity addition, flexion/extension and rotation wrist unit Prosthetic Additions Upper Extremity L6625 Upper extremity addition, rotation wrist unit with cable lock Prosthetic Additions Upper Extremity L6628 Upper extremity addition, quick disconnect hook adapter, otto bock or equal Prosthetic Additions Upper Extremity L6629 Upper extremity addition, quick disconnect lamination collar with coupling Prosthetic piece, otto bock or equal Additions Upper Extremity L6630 Upper extremity addition, stainless steel, any wrist Prosthetic Additions Upper Extremity L6632 Upper extremity addition, latex suspension sleeve, each Prosthetic Additions Upper Extremity L6635 Upper extremity addition, lift assist for elbow Prosthetic Additions Upper Extremity L6637 Upper extremity addition, nudge control elbow lock Prosthetic Additions Upper Extremity L6640 Upper extremity additions, shoulder abduction joint, pair Prosthetic Additions Upper Extremity L6641 Upper extremity addition, excursion amplifier, pulley type Prosthetic Additions Upper Extremity L6642 Upper extremity addition, excursion amplifier, lever type Prosthetic Additions Upper Extremity L6645 Upper extremity addition, shoulder flexion-abduction joint, each Prosthetic Additions Upper Extremity L6650 Upper extremity addition, shoulder universal joint, each Prosthetic Additions Upper Extremity L6655 Upper extremity addition, standard control cable, extra Prosthetic Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Upper Extremity L6660 Upper extremity addition, heavy duty control cable Prosthetic Additions Upper Extremity L6665 Upper extremity addition, teflon, or equal, cable lining Prosthetic Additions Upper Extremity L6670 Upper extremity addition, hook to hand, cable adapter Prosthetic Additions Upper Extremity L6672 Upper extremity addition, harness, chest or shoulder, saddle type Prosthetic Additions Upper Extremity L6675 Upper extremity addition, harness, (e.g., figure of eight type), single cable Prosthetic design Additions Upper Extremity L6676 Upper extremity addition, harness, (e.g., figure of eight type), dual cable design Prosthetic Additions Upper Extremity L6680 Upper extremity addition, test socket, wrist disarticulation or below elbow Prosthetic Additions Upper Extremity L6682 Upper extremity addition, test socket, elbow disarticulation or above elbow Prosthetic Additions Upper Extremity L6684 Upper extremity addition, test socket, shoulder disarticulation or interscapular Prosthetic thoracic Additions Upper Extremity L6686 Upper extremity addition, suction socket Prosthetic Additions Upper Extremity L6687 Upper extremity addition, frame type socket, below elbow or wrist Prosthetic disarticulation Additions Upper Extremity L6688 Upper extremity addition, frame type socket, above elbow or elbow Prosthetic disarticulation Additions Upper Extremity L6689 Upper extremity addition, frame type socket, shoulder disarticulation Prosthetic Additions Upper Extremity L6690 Upper extremity addition, frame type socket, interscapular-thoracic Prosthetic Additions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Upper Extremity L6691 Upper extremity addition, removable insert, each Prosthetic Additions Upper Extremity L6692 Upper extremity addition, silicone gel insert or equal, each Prosthetic Additions Upper Extremity L6693 Upper extremity addition, locking elbow, forearm counterbalance Prosthetic Additions Upper Extremity L6694 Addition to upper extremity prosthesis, below elbow/above elbow, custom Prosthetic fabricated from existing mold or prefabricated, socket insert, silicone gel, Additions elastomeric or equal, for use with locking mechanism Upper Extremity L6698 Addition to upper extremity prosthesis, below elbow/above elbow, lock Prosthetic mechanism, excludes socket insert Additions Upper Extremity L7499 Upper extremity prosthesis, not otherwise specified Prosthetics, Not Otherwise Specified (NOS) Vacuum Pumps, L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume Lower Limb management and moisture evacuation system Prosthetic Additions Various Medical A4450 Tape, non-waterproof, per 18 square inches Supplies Including Tapes and Surgical Dressings Various Medical A4452 Tape, waterproof, per 18 square inches Supplies Including Tapes and Surgical Dressings Various Medical A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per ounce Supplies Including Tapes and Surgical Dressings Various Medical A4456 Adhesive remover, wipes, any type, each Supplies Including Tapes and Surgical Dressings
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Various Medical A4459 Manual pump-operated enema system, includes balloon, catheter and all Supplies accessories, reusable, any type Including Tapes and Surgical Dressings Various Medical A4466 Garment, belt, sleeve or other covering, elastic or similar stretchable material, Supplies any type, each Including Tapes and Surgical Dressings Various Medical A4467 Belt, strap, sleeve, garment, or covering, any type Supplies Including Tapes and Surgical Dressings Various Medical A4481 Tracheostoma filter, any type, any size, each Supplies Including Tapes and Surgical Dressings Various Medical A4483 Moisture exchanger, disposable, for use with invasive mechanical ventilation Supplies Including Tapes and Surgical Dressings Various Medical A4520 Incontinence garment, any type, (e.g., brief, diaper), each Supplies Including Tapes and Surgical Dressings Various Medical A4550 Surgical trays Supplies Including Tapes and Surgical Dressings Various Medical A4554 Disposable underpads, all sizes Supplies Including Tapes and Surgical Dressings Various Medical A4556 Electrodes, (e.g., apnea monitor), per pair Supplies Including Tapes
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
and Surgical Dressings Various Medical A4557 Lead wires, (e.g., apnea monitor), per pair Supplies Including Tapes and Surgical Dressings Various Medical A4561 Pessary, rubber, any type Supplies Including Tapes and Surgical Dressings Various Medical A4562 Pessary, non rubber, any type Supplies Including Tapes and Surgical Dressings Various Medical A4565 Slings Supplies Including Tapes and Surgical Dressings Various Medical A4570 Splint Supplies Including Tapes and Surgical Dressings Various Medical A4595 Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) Supplies Including Tapes and Surgical Dressings Various Medical A4604 Tubing with integrated heating element for use with positive airway pressure Supplies device Including Tapes and Surgical Dressings Various Medical A4605 Tracheal suction catheter, closed system, each Supplies Including Tapes and Surgical Dressings Various Medical A4606 Oxygen probe for use with oximeter device, replacement Supplies
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Including Tapes and Surgical Dressings Various Medical A4608 Transtracheal oxygen catheter, each Supplies Including Tapes and Surgical Dressings Various L5629 Addition to lower extremity, below knee, acrylic socket Prosthetic Sockets Various L5630 Addition to lower extremity, symes type, expandable wall socket Prosthetic Sockets Various L5631 Addition to lower extremity, above knee or knee disarticulation, acrylic socket Prosthetic Sockets Various L5632 Addition to lower extremity, symes type, 'ptb' brim design socket Prosthetic Sockets Various L5634 Addition to lower extremity, symes type, posterior opening (canadian) socket Prosthetic Sockets Various L5636 Addition to lower extremity, symes type, medial opening socket Prosthetic Sockets Various L5637 Addition to lower extremity, below knee, total contact Prosthetic Sockets Various L5638 Addition to lower extremity, below knee, leather socket Prosthetic Sockets Various L5639 Addition to lower extremity, below knee, wood socket Prosthetic Sockets Various L5640 Addition to lower extremity, knee disarticulation, leather socket Prosthetic Sockets Various L5642 Addition to lower extremity, above knee, leather socket Prosthetic Sockets Various L5643 Addition to lower extremity, hip disarticulation, flexible inner socket, external Prosthetic frame Sockets
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Various L5644 Addition to lower extremity, above knee, wood socket Prosthetic Sockets Various L5645 Addition to lower extremity, below knee, flexible inner socket, external frame Prosthetic Sockets Various L5646 Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket Prosthetic Sockets Various L5647 Addition to lower extremity, below knee suction socket Prosthetic Sockets Various L5648 Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket Prosthetic Sockets Various L5649 Addition to lower extremity, ischial containment/narrow m-l socket Prosthetic Sockets Various L5650 Additions to lower extremity, total contact, above knee or knee disarticulation Prosthetic socket Sockets Various L5651 Addition to lower extremity, above knee, flexible inner socket, external frame Prosthetic Sockets Various L5652 Addition to lower extremity, suction suspension, above knee or knee Prosthetic disarticulation socket Sockets Various L5653 Addition to lower extremity, knee disarticulation, expandable wall socket Prosthetic Sockets Various Services, S8999 Resuscitation bag (for use by patient on artificial respiration during power Fees, and Costs failure or other catastrophic event) Voice Prosthetics L8500 Artificial larynx, any type and Accessories Voice Prosthetics L8501 Tracheostomy speaking valve and Accessories Voice Prosthetics L8507 Tracheo-esophageal voice prosthesis, patient inserted, any type, each and Accessories Voice Prosthetics L8509 Tracheo-esophageal voice prosthesis, inserted by a licensed health care and Accessories provider, any type Voice Prosthetics L8615 Headset/headpiece for use with cochlear implant device, replacement and Accessories Walking Aids and E0100 Cane, includes canes of all materials, adjustable or fixed, with tip Attachments
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Walking Aids and E0105 Cane, quad or three prong, includes canes of all materials, adjustable or fixed, Attachments with tips Walking Aids and E0110 Crutches, forearm, includes crutches of various materials, adjustable or fixed, Attachments pair, complete with tips and handgrips Walking Aids and E0111 Crutch forearm, includes crutches of various materials, adjustable or fixed, Attachments each, with tip and handgrips Walking Aids and E0112 Crutches underarm, wood, adjustable or fixed, pair, with pads, tips and Attachments handgrips Walking Aids and E0113 Crutch underarm, wood, adjustable or fixed, each, with pad, tip and handgrip Attachments Walking Aids and E0114 Crutches underarm, other than wood, adjustable or fixed, pair, with pads, tips Attachments and handgrips Walking Aids and E0116 Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, handgrip, Attachments with or without shock absorber, each Walking Aids and E0118 Crutch substitute, lower leg platform, with or without wheels, each Attachments Walking Aids and E0130 Walker, rigid (pickup), adjustable or fixed height Attachments Walking Aids and E0135 Walker, folding (pickup), adjustable or fixed height Attachments Walking Aids and E0140 Walker, with trunk support, adjustable or fixed height, any type Attachments Walking Aids and E0141 Walker, rigid, wheeled, adjustable or fixed height Attachments Walking Aids and E0143 Walker, folding, wheeled, adjustable or fixed height Attachments Walking Aids and E0144 Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior Attachments seat Walking Aids and E0147 Walker, heavy duty, multiple braking system, variable wheel resistance Attachments Walking Aids and E0148 Walker, heavy duty, without wheels, rigid or folding, any type, each Attachments Walking Aids and E0149 Walker, heavy duty, wheeled, rigid or folding, any type Attachments Walking Aids and E0153 Platform attachment, forearm crutch, each Attachments Walking Aids and E0154 Platform attachment, walker, each Attachments Walking Aids and E0155 Wheel attachment, rigid pick-up walker, per pair Attachments Walking Aids and E0156 Seat attachment, walker Attachments Walking Aids and E0157 Crutch attachment, walker, each Attachments
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Walking Aids and E0158 Leg extensions for walker, per set of four (4) Attachments Walking Aids and E0159 Brake attachment for wheeled walker, replacement, each Attachments Wheelchair E0950 Wheelchair accessory, tray, each Accessories Wheelchair E0951 Heel loop/holder, any type, with or without ankle strap, each Accessories Wheelchair E0952 Toe loop/holder, any type, each Accessories Wheelchair E0953 Wheelchair accessory, lateral thigh or knee support, any type including fixed Accessories mounting hardware, each Wheelchair E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting Accessories hardware, each foot Wheelchair E0955 Wheelchair accessory, headrest, cushioned, any type, including fixed mounting Accessories hardware, each Wheelchair E0956 Wheelchair accessory, lateral trunk or hip support, any type, including fixed Accessories mounting hardware, each Wheelchair E0957 Wheelchair accessory, medial thigh support, any type, including fixed mounting Accessories hardware, each Wheelchair E0958 Manual wheelchair accessory, one-arm drive attachment, each Accessories Wheelchair E0959 Manual wheelchair accessory, adapter for amputee, each Accessories Wheelchair E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any type Accessories mounting hardware Wheelchair E0961 Manual wheelchair accessory, wheel lock brake extension (handle), each Accessories Wheelchair E0966 Manual wheelchair accessory, headrest extension, each Accessories Wheelchair E0967 Manual wheelchair accessory, hand rim with projections, any type, replacement Accessories only, each Wheelchair E0968 Commode seat, wheelchair Accessories Wheelchair E0969 Narrowing device, wheelchair Accessories Wheelchair E0971 Manual wheelchair accessory, anti-tipping device, each Accessories Wheelchair E0973 Wheelchair accessory, adjustable height, detachable armrest, complete Accessories assembly, each Wheelchair E0974 Manual wheelchair accessory, anti-rollback device, each Accessories Wheelchair E0978 Wheelchair accessory, positioning belt/safety belt/pelvic strap, each Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchair E0980 Safety vest, wheelchair Accessories Wheelchair E0981 Wheelchair accessory, seat upholstery, replacement only, each Accessories Wheelchair E0982 Wheelchair accessory, back upholstery, replacement only, each Accessories Wheelchair E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to Accessories motorized wheelchair, joystick control Wheelchair E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to Accessories motorized wheelchair, tiller control Wheelchair E0986 Manual wheelchair accessory, push-rim activated power assist system Accessories Wheelchair E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair Accessories Wheelchair E0990 Wheelchair accessory, elevating leg rest, complete assembly, each Accessories Wheelchair E0992 Manual wheelchair accessory, solid seat insert Accessories Wheelchair E0994 Arm rest, each Accessories Wheelchair E0995 Wheelchair accessory, calf rest/pad, replacement only, each Accessories Wheelchair E1002 Wheelchair accessory, power seating system, tilt only Accessories Wheelchair E1003 Wheelchair accessory, power seating system, recline only, without shear Accessories reduction Wheelchair E1004 Wheelchair accessory, power seating system, recline only, with mechanical Accessories shear reduction Wheelchair E1005 Wheelchair accessory, power seatng system, recline only, with power shear Accessories reduction Wheelchair E1006 Wheelchair accessory, power seating system, combination tilt and recline, Accessories without shear reduction Wheelchair E1007 Wheelchair accessory, power seating system, combination tilt and recline, with Accessories mechanical shear reduction Wheelchair E1008 Wheelchair accessory, power seating system, combination tilt and recline, with Accessories power shear reduction Wheelchair E1010 Wheelchair accessory, addition to power seating system, power leg elevation Accessories system, including leg rest, pair Wheelchair E1012 Wheelchair accessory, addition to power seating system, center mount power Accessories elevating leg rest/platform, complete system, any type, each Wheelchair E1014 Reclining back, addition to pediatric size wheelchair Accessories Wheelchair E1015 Shock absorber for manual wheelchair, each Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchair E1016 Shock absorber for power wheelchair, each Accessories Wheelchair E1017 Heavy duty shock absorber for heavy duty or extra heavy duty manual Accessories wheelchair, each Wheelchair E1020 Residual limb support system for wheelchair, any type Accessories Wheelchair E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting Accessories hardware for joystick, other control interface or positioning accessory Wheelchair E1029 Wheelchair accessory, ventilator tray, fixed Accessories Wheelchair E1030 Wheelchair accessory, ventilator tray, gimbaled Accessories Wheelchair E1031 Rollabout chair, any and all types with casters 5" or greater Accessories Wheelchair E1035 Multi-positional patient transfer system, with integrated seat, operated by care Accessories giver, patient weight capacity up to and including 300 lbs Wheelchair E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, Accessories operated by caregiver, patient weight capacity greater than 300 lbs Wheelchair E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to Mobile Arm wheelchair, balanced, adjustable Supports Wheelchair E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached to Mobile Arm wheelchair, balanced, adjustable rancho type Supports Wheelchair E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to Mobile Arm wheelchair, balanced, reclining Supports Wheelchair E2629 Wheelchair accessory, shoulder elbow, mobile arm support attached to Mobile Arm wheelchair, balanced, friction arm support (friction dampening to proximal and Supports distal joints) Wheelchair E2630 Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension Mobile Arm arm and hand support, overhead elbow forearm hand sling support, yoke type Supports suspension support Wheelchair E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm Mobile Arm Supports Wheelchair E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker Mobile Arm arm with elastic balance control Supports Wheelchair E2633 Wheelchair accessory, addition to mobile arm support, supinator Mobile Arm Supports
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchair Seat E2601 General use wheelchair seat cushion, width less than 22 inches, any depth and Back Cushions Wheelchair Seat E2602 General use wheelchair seat cushion, width 22 inches or greater, any depth and Back Cushions Wheelchair Seat E2603 Skin protection wheelchair seat cushion, width less than 22 inches, any depth and Back Cushions Wheelchair Seat E2604 Skin protection wheelchair seat cushion, width 22 inches or greater, any depth and Back Cushions Wheelchair Seat E2605 Positioning wheelchair seat cushion, width less than 22 inches, any depth and Back Cushions Wheelchair Seat E2606 Positioning wheelchair seat cushion, width 22 inches or greater, any depth and Back Cushions Wheelchair Seat E2607 Skin protection and positioning wheelchair seat cushion, width less than 22 and Back inches, any depth Cushions Wheelchair Seat E2608 Skin protection and positioning wheelchair seat cushion, width 22 inches or and Back greater, any depth Cushions Wheelchair Seat E2609 Custom fabricated wheelchair seat cushion, any size and Back Cushions Wheelchair Seat E2611 General use wheelchair back cushion, width less than 22 inches, any height, and Back including any type mounting hardware Cushions Wheelchair Seat E2612 General use wheelchair back cushion, width 22 inches or greater, any height, and Back including any type mounting hardware Cushions Wheelchair Seat E2613 Positioning wheelchair back cushion, posterior, width less than 22 inches, any and Back height, including any type mounting hardware Cushions Wheelchair Seat E2614 Positioning wheelchair back cushion, posterior, width 22 inches or greater, any and Back height, including any type mounting hardware Cushions Wheelchair Seat E2615 Positioning wheelchair back cushion, posterior-lateral, width less than 22 and Back inches, any height, including any type mounting hardware Cushions
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchair Seat E2616 Positioning wheelchair back cushion, posterior-lateral, width 22 inches or and Back greater, any height, including any type mounting hardware Cushions Wheelchair Seat E2617 Custom fabricated wheelchair back cushion, any size, including any type and Back mounting hardware Cushions Wheelchair Seat E2619 Replacement cover for wheelchair seat cushion or back cushion, each and Back Cushions Wheelchair Seat E2620 Positioning wheelchair back cushion, planar back with lateral supports, width and Back less than 22 inches, any height, including any type mounting hardware Cushions Wheelchair Seat E2621 Positioning wheelchair back cushion, planar back with lateral supports, width and Back 22 inches or greater, any height, including any type mounting hardware Cushions Wheelchair Seat E2622 Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, and Back any depth Cushions Wheelchair Seat E2623 Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, and Back any depth Cushions Wheelchair Seat E2624 Skin protection and positioning wheelchair seat cushion, adjustable, width less and Back than 22 inches, any depth Cushions Wheelchair Seat E2625 Skin protection and positioning wheelchair seat cushion, adjustable, width 22 and Back inches or greater, any depth Cushions Wheelchairs, K0001 Standard wheelchair Components, and Accessories Wheelchairs, K0002 Standard hemi (low seat) wheelchair Components, and Accessories Wheelchairs, K0003 Lightweight wheelchair Components, and Accessories Wheelchairs, K0004 High strength, lightweight wheelchair Components, and Accessories Wheelchairs, K0005 Ultralightweight wheelchair Components, and Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchairs, K0006 Heavy duty wheelchair Components, and Accessories Wheelchairs, K0007 Extra heavy duty wheelchair Components, and Accessories Wheelchairs, K0008 Custom manual wheelchair/base Components, and Accessories Wheelchairs, K0009 Other manual wheelchair/base Components, and Accessories Wheelchairs, K0010 Standard - weight frame motorized/power wheelchair Components, and Accessories Wheelchairs, K0012 Lightweight portable motorized/power wheelchair Components, and Accessories Wheelchairs, K0013 Custom motorized/power wheelchair base Components, and Accessories Wheelchairs, K0014 Other motorized/power wheelchair base Components, and Accessories Wheelchairs, K0015 Detachable, non-adjustable height armrest, replacement only, each Components, and Accessories Wheelchairs, K0017 Detachable, adjustable height armrest, base, replacement only, each Components, and Accessories Wheelchairs, K0018 Detachable, adjustable height armrest, upper portion, replacement only, each Components, and Accessories Wheelchairs, K0019 Arm pad, replacement only, each Components, and Accessories Wheelchairs, K0020 Fixed, adjustable height armrest, pair Components, and Accessories Wheelchairs, K0037 High mount flip-up footrest, each Components, and Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchairs, K0038 Leg strap, each Components, and Accessories Wheelchairs, K0039 Leg strap, h style, each Components, and Accessories Wheelchairs, K0040 Adjustable angle footplate, each Components, and Accessories Wheelchairs, K0041 Large size footplate, each Components, and Accessories Wheelchairs, K0042 Standard size footplate, replacement only, each Components, and Accessories Wheelchairs, K0043 Footrest, lower extension tube, replacement only, each Components, and Accessories Wheelchairs, K0044 Footrest, upper hanger bracket, replacement only, each Components, and Accessories Wheelchairs, K0045 Footrest, complete assembly, replacement only, each Components, and Accessories Wheelchairs, K0046 Elevating legrest, lower extension tube, replacement only, each Components, and Accessories Wheelchairs, K0047 Elevating legrest, upper hanger bracket, replacement only, each Components, and Accessories Wheelchairs, K0050 Ratchet assembly, replacement only Components, and Accessories Wheelchairs, K0051 Cam release assembly, footrest or legrest, replacement only, each Components, and Accessories Wheelchairs, K0052 Swingaway, detachable footrests, replacement only, each Components, and Accessories Wheelchairs, K0053 Elevating footrests, articulating (telescoping), each Components, and Accessories
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchairs, K0056 Seat height less than 17" or equal to or greater than 21" for a high strength, Components, and lightweight, or ultralightweight wheelchair Accessories Wheelchairs, K0065 Spoke protectors, each Components, and Accessories Wheelchairs, K0069 Rear wheel assembly, complete, with solid tire, spokes or molded, replacement Components, and only, each Accessories Wheelchairs, K0070 Rear wheel assembly, complete, with pneumatic tire, spokes or molded, Components, and replacement only, each Accessories Wheelchairs, K0071 Front caster assembly, complete, with pneumatic tire, replacement only, each Components, and Accessories Wheelchairs, K0072 Front caster assembly, complete, with semi-pneumatic tire, replacement only, Components, and each Accessories Wheelchairs, K0073 Caster pin lock, each Components, and Accessories Wheelchairs, K0077 Front caster assembly, complete, with solid tire, replacement only, each Components, and Accessories Wheelchairs, K0098 Drive belt for power wheelchair, replacement only Components, and Accessories Wheelchairs, K0105 Iv hanger, each Components, and Accessories Wheelchairs, K0108 Wheelchair component or accessory, not otherwise specified Components, and Accessories Wheelchairs, K0195 Elevating leg rests, pair (for use with capped rental wheelchair base) Components, and Accessories Wheelchairs, K0813 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient Power Operated weight capacity up to and including 300 pounds Wheelchairs, K0814 Power wheelchair, group 1 standard, portable, captains chair, patient weight Power Operated capacity up to and including 300 pounds Wheelchairs, K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight Power Operated capacity up to and including 300 pounds Wheelchairs, K0816 Power wheelchair, group 1 standard, captains chair, patient weight capacity up Power Operated to and including 300 pounds
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchairs, K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient Power Operated weight capacity up to and including 300 pounds Wheelchairs, K0821 Power wheelchair, group 2 standard, portable, captains chair, patient weight Power Operated capacity up to and including 300 pounds Wheelchairs, K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight Power Operated capacity up to and including 300 pounds Wheelchairs, K0823 Power wheelchair, group 2 standard, captains chair, patient weight capacity up Power Operated to and including 300 pounds Wheelchairs, K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight Power Operated capacity 301 to 450 pounds Wheelchairs, K0825 Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity Power Operated 301 to 450 pounds Wheelchairs, K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient Power Operated weight capacity 451 to 600 pounds Wheelchairs, K0827 Power wheelchair, group 2 very heavy duty, captains chair, patient weight Power Operated capacity 451 to 600 pounds Wheelchairs, K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient Power Operated weight capacity 601 pounds or more Wheelchairs, K0829 Power wheelchair, group 2 extra heavy duty, captains chair, patient weight 601 Power Operated pounds or more Wheelchairs, K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, Power Operated patient weight capacity up to and including 300 pounds Wheelchairs, K0836 Power wheelchair, group 2 standard, single power option, captains chair, patient Power Operated weight capacity up to and including 300 pounds Wheelchairs, K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid Power Operated seat/back, patient weight capacity 301 to 450 pounds Wheelchairs, K0838 Power wheelchair, group 2 heavy duty, single power option, captains chair, Power Operated patient weight capacity 301 to 450 pounds Wheelchairs, K0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid Power Operated seat/back, patient weight capacity 451 to 600 pounds Wheelchairs, K0840 Power wheelchair, group 2 extra heavy duty, single power option, sling/solid Power Operated seat/back, patient weight capacity 601 pounds or more Wheelchairs, K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid Power Operated seat/back, patient weight capacity up to and including 300 pounds Wheelchairs, K0842 Power wheelchair, group 2 standard, multiple power option, captains chair, Power Operated patient weight capacity up to and including 300 pounds Wheelchairs, K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid Power Operated seat/back, patient weight capacity 301 to 450 pounds Wheelchairs, K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight Power Operated capacity up to and including 300 pounds Wheelchairs, K0849 Power wheelchair, group 3 standard, captains chair, patient weight capacity up Power Operated to and including 300 pounds Wheelchairs, K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight Power Operated capacity 301 to 450 pounds
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wheelchairs, K0851 Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity Power Operated 301 to 450 pounds Wheelchairs, K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient Power Operated weight capacity 451 to 600 pounds Wheelchairs, K0853 Power wheelchair, group 3 very heavy duty, captains chair, patient weight Power Operated capacity 451 to 600 pounds Wheelchairs, K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient Power Operated weight capacity 601 pounds or more Wheelchairs, K0855 Power wheelchair, group 3 extra heavy duty, captains chair, patient weight Power Operated capacity 601 pounds or more Wheelchairs, K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, Power Operated patient weight capacity up to and including 300 pounds Wheelchairs, K0857 Power wheelchair, group 3 standard, single power option, captains chair, patient Power Operated weight capacity up to and including 300 pounds Wheelchairs, K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid Power Operated seat/back, patient weight 301 to 450 pounds Wheelchairs, K0859 Power wheelchair, group 3 heavy duty, single power option, captains chair, Power Operated patient weight capacity 301 to 450 pounds Wheelchairs, K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid Power Operated seat/back, patient weight capacity 451 to 600 pounds Wheelchairs, K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid Power Operated seat/back, patient weight capacity up to and including 300 pounds Wheelchairs, K0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid Power Operated seat/back, patient weight capacity 301 to 450 pounds Wheelchairs, K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid Power Operated seat/back, patient weight capacity 451 to 600 pounds Wheelchairs, K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid Power Operated seat/back, patient weight capacity 601 pounds or more Wheelchairs, K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid Power Operated seat/back, patient weight capacity up to and including 300 pounds Wound Therapy E2402 Negative pressure wound therapy electrical pump, stationary or portable Pumps Wrist L6050 Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad Disarticulation, Hand Prosthetics Wrist L6055 Wrist disarticulation, molded socket with expandable interface, flexible elbow Disarticulation, hinges, triceps pad Hand Prosthetics Wrist-hand L3906 Wrist hand orthosis, without joints, may include soft interface, straps, custom Orthotics fabricated, includes fitting and adjustment Wrist-hand L3908 Wrist hand orthosis, wrist extension control cock-up, non molded, Orthotics prefabricated, off-the-shelf
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
Wrist-hand-finger L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been Orthotics trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Wrist-hand-finger L3808 Wrist hand finger orthosis, rigid without joints, may include soft interface Orthotics material; straps, custom fabricated, includes fitting and adjustment Wrist-hand-finger L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any Orthotics type Wrist-hand-finger L3900 Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ Orthotics flexion, finger flexion/extension, wrist or finger driven, custom fabricated Wrist-hand-finger L3901 Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ Orthotics flexion, finger flexion/extension, cable driven, custom fabricated Wrist-hand-finger L3904 Wrist hand finger orthosis, external powered, electric, custom fabricated Orthotics
Covered Modifier Listing
NU New DME purchase RO Rental Only RR DME Rental SC Medically Necessary Service of Supply
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021
PRO_71448E Internal Approved 03102021 FL1WMCGDE71448E_0000 ©WellCare 2021