CodeMap® CodeMap® Contractor Policy Detail

LCD	Effective Date	Revision Effective Date	Title	CPT Codes Covered in LCD
L33312	10/01/2015	01/01/2020	Wheelchair Seating	A9900 E0953 E0955 E0956 E0957 E0960 E0966 E0992 E1028 E2231 E2291 E2292 E2293 E2294 E2601 E2602 E2603 E2604 E2605 E2606 E2607 E2608 E2609 E2610 E2611 E2612 E2613 E2614 E2615 E2616 E2617 E2619 E2620 E2621 E2622 E2623 E2624 E2625 K0108 K0669
L33317	10/01/2015	01/01/2024	External Breast Prostheses	A4280 L8000 L8001 L8002 L8010 L8015 L8020 L8030 L8031 L8032 L8033 L8035 L8039
L33318	10/01/2015	10/01/2024	Knee Orthoses	A4467 A9270 K0672 L1810 L1812 L1820 L1821 L1830 L1831 L1832 L1833 L1834 L1836 L1840 L1843 L1844 L1845 L1846 L1847 L1848 L1850 L1851 L1852 L1860 L2275 L2320 L2330 L2385 L2390 L2395 L2397 L2405 L2415 L2425 L2430 L2492 L2750 L2755 L2780 L2785 and more.....
L33369	10/01/2015	01/01/2020	Therapeutic Shoes for Persons with Diabetes	A5500 A5501 A5503 A5504 A5505 A5506 A5507 A5508 A5510 A5512 A5513 A5514
L33370	10/01/2015	01/01/2024	Nebulizers	A4216 A4217 A4218 A4619 A7003 A7004 A7005 A7006 A7007 A7008 A7009 A7010 A7012 A7013 A7014 A7015 A7016 A7017 A7018 A7525 E0565 E0570 E0572 E0574 E0575 E0580 E0585 E1372 G0333 J2545 J7604 J7605 J7606 J7607 J7608 J7609 J7610 J7611 J7612 J7613 and more.....
L33610	10/01/2015	01/01/2024	Intravenous Immune Globulin	A4223 J1459 J1554 J1556 J1557 J1561 J1566 J1568 J1569 J1572 J1573 J1576 J1599 J2791 Q2052
L33611	10/01/2015	08/08/2021	Oral Appliances for Obstructive Sleep Apnea	A9270 E0485 E0486 E1399
L33612	10/01/2015	01/01/2024	Suction Pumps	A4216 A4217 A4605 A4624 A4628 A7000 A7001 A7002 A7047 A9272 E0600 E2000 K0743 K0744 K0745 K0746
L33641	10/01/2015	01/01/2020	Orthopedic Footwear	A9283 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3031 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 and more.....
L33642	10/01/2015	05/01/2021	Pressure Reducing Support Surfaces - Group 2	E0193 E0277 E0371 E0372 E0373 E1399
L33686	10/01/2015	01/23/2024	Ankle-Foot/Knee-Ankle-Foot Orthosis	A4467 A9283 A9285 L1900 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980 L1990 L2000 L2005 L2006 L2010 L2020 L2030 L2034 L2035 L2036 L2037 L2038 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 and more.....
L33690	10/01/2015	01/01/2020	Automatic External Defibrillators	A9999 E0617 K0606 K0607 K0608 K0609
L33692	10/01/2015	05/01/2021	Pressure Reducing Support Surfaces - Group 3	E0194
L33718	10/01/2015	01/01/2024	Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea	A4604 A7027 A7028 A7029 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044 A7045 A7046 E0470 E0471 E0561 E0562 E0601
L33733	10/01/2015	01/01/2020	Canes and Crutches	A4635 A4636 A4637 A9270 E0100 E0105 E0110 E0111 E0112 E0113 E0114 E0116 E0117 E0118 E0153
L33735	10/01/2015	01/01/2020	Cold Therapy	A9270 A9273 E0218
L33736	10/01/2015	01/01/2020	Commodes	E0163 E0165 E0167 E0168 E0170 E0171 E0172 E0175 E0244
L33737	10/01/2015	01/01/2020	Eye Prostheses	L9900 V2623 V2624 V2625 V2626 V2627 V2628 V2629
L33738	10/01/2015	01/01/2020	Facial Prostheses	A4364 A4450 A4452 A4455 A4456 A5120 L8040 L8041 L8042 L8043 L8044 L8045 L8046 L8047 L8048 L8049 V2623 V2629
L33739	10/01/2015	10/01/2024	Speech Generating Devices (SGD)	E2500 E2502 E2504 E2506 E2508 E2510 E2511 E2512 E2513 E2599
L33784	10/01/2015	01/01/2020	Heating Pads and Heat Lamps	A9273 A9999 E0200 E0205 E0210 E0215 E0217 E0225 E0236 E0239 E0249 E1399
L33785	10/01/2015	10/01/2022	High Frequency Chest Wall Oscillation Devices	A7025 A7026 E0483
L33786	10/01/2015	01/01/2020	Intrapulmonary Percussive Ventilation System	E0481
L33787	10/01/2015	09/01/2024	Lower Limb Prostheses	L5000 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 L5250 L5270 L5280 L5301 L5312 L5321 L5331 L5341 L5400 L5410 L5420 L5430 L5450 L5460 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 and more.....
L33788	10/01/2015	01/01/2020	Manual Wheelchair Bases	E1037 E1038 E1039 E1161 E1229 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0008 K0009
L33789	10/01/2015	05/16/2023	Power Mobility Devices	E0983 E0984 E0986 K0013 K0800 K0801 K0802 K0806 K0807 K0808 K0812 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 and more.....
L33790	10/01/2015	01/01/2020	Spinal Orthoses: TLSO and LSO	A4467 A9270 L0450 L0452 L0454 L0455 L0456 L0457 L0458 L0460 L0462 L0464 L0466 L0467 L0468 L0469 L0470 L0472 L0480 L0482 L0484 L0486 L0488 L0490 L0491 L0492 L0621 L0622 L0623 L0624 L0625 L0626 L0627 L0628 L0629 L0630 L0631 L0632 L0633 L0634 and more.....
L33791	10/01/2015	01/01/2020	Walkers	A4636 A4637 A9270 A9900 E0130 E0135 E0140 E0141 E0143 E0144 E0147 E0148 E0149 E0154 E0155 E0156 E0157 E0158 E0159 E1399
L33792	10/01/2015	04/01/2024	Wheelchair Options/Accessories	A9270 A9900 E0705 E0950 E0951 E0952 E0954 E0958 E0959 E0961 E0967 E0971 E0973 E0974 E0978 E0981 E0982 E0985 E0988 E0990 E0995 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1009 E1010 E1011 E1012 E1014 E1015 E1016 E1017 E1018 E1020 E1028 E1029 and more.....
L33793	10/01/2015	10/01/2020	Refractive Lenses	V2020 V2025 V2100 V2101 V2102 V2103 V2104 V2105 V2106 V2107 V2108 V2109 V2110 V2111 V2112 V2113 V2114 V2115 V2118 V2121 V2199 V2200 V2201 V2202 V2203 V2204 V2205 V2206 V2207 V2208 V2209 V2210 V2211 V2212 V2213 V2214 V2215 V2218 V2219 V2220 and more.....
L33794	10/01/2015	10/01/2024	External Infusion Pumps	A4221 A4222 A4223 A4224 A4225 A4305 A4306 A4602 A9270 A9274 E0776 E0779 E0780 E0781 E0784 E0791 E1399 J0133 J0285 J0287 J0288 J0289 J0895 J1171 J1250 J1265 J1325 J1455 J1457 J1551 J1555 J1558 J1559 J1561 J1562 J1569 J1570 J1574 J1575 J1811 and more.....
L33795	10/01/2015	01/01/2020	Mechanical In-exsufflation Devices	A7020 E0482
L33796	10/01/2015	01/01/2024	Osteogenesis Stimulators	A4559 E0747 E0748 E0760
L33797	10/01/2015	04/01/2023	Oxygen and Oxygen Equipment	A4575 A4606 A4608 A4615 A4616 A4617 A4619 A4620 A7525 A9900 E0424 E0425 E0430 E0431 E0433 E0434 E0435 E0439 E0440 E0441 E0442 E0443 E0444 E0445 E0446 E0447 E0455 E0555 E0580 E1352 E1353 E1354 E1355 E1356 E1357 E1358 E1390 E1391 E1392 E1405 and more.....
L33799	10/01/2015	01/01/2020	Patient Lifts	E0621 E0625 E0630 E0635 E0636 E0639 E0640 E1035 E1036
L33800	10/01/2015	01/01/2024	Respiratory Assist Devices	A4604 A7027 A7028 A7029 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044 A7045 A7046 E0470 E0471 E0561 E0562
L33801	10/01/2015	07/02/2023	Seat Lift Mechanisms	E0172 E0627 E0629
L33802	10/01/2015	01/01/2024	Transcutaneous Electrical Nerve Stimulators (TENS)	A4557 A4595 E0720 E0730 E0731
L33803	10/01/2015	01/01/2024	Urological Supplies	A4217 A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4321 A4322 A4326 A4327 A4328 A4331 A4332 A4333 A4334 A4335 A4336 A4338 A4340 A4341 A4342 A4344 A4346 A4349 A4351 A4352 A4353 A4354 A4355 A4356 A4357 A4358 A4360 A4402 A4450 A4452 A4455 and more.....
L33820	10/01/2015	01/01/2020	Hospital Beds And Accessories	E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0271 E0272 E0273 E0274 E0280 E0290 E0291 E0292 E0293 E0294 E0295 E0296 E0297 E0301 E0302 E0303 E0304 E0305 E0310 E0315 E0316 E0328 E0329 E0910 E0911 E0912 E0940 E1399
L33821	10/01/2015	01/01/2024	Negative Pressure Wound Therapy Pumps	A6550 A7000 E2402
L33822	10/01/2015	10/01/2024	Glucose Monitors	A4233 A4234 A4235 A4236 A4238 A4239 A4244 A4245 A4246 A4247 A4250 A4253 A4255 A4256 A4257 A4258 A4259 A4271 A9275 A9276 A9277 A9278 A9999 E0607 E0620 E1399 E2100 E2101 E2102 E2103 E2104
L33823	10/01/2015	01/01/2020	Cervical Traction Devices	E0840 E0849 E0850 E0855 E0856 E0860
L33824	10/01/2015	04/01/2024	Immunosuppressive Drugs	J0485 J2919 J7500 J7501 J7502 J7503 J7504 J7505 J7507 J7508 J7509 J7510 J7511 J7512 J7513 J7515 J7516 J7517 J7518 J7520 J7525 J7527 J7599 J8530 J8610 Q0510 Q0511 Q0512
L33825	10/01/2015	01/01/2020	Infrared Heating Pad Systems	A4639 E0221
L33826	10/01/2015	01/01/2024	Oral Anticancer Drugs	A9270 J8498 J8597 J8999 Q0511 Q0512
L33827	10/01/2015	01/01/2024	Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)	J8501 J8540 J8650 J8655 J8670 Q0161 Q0162 Q0163 Q0164 Q0166 Q0167 Q0169 Q0173 Q0174 Q0175 Q0177 Q0180 Q0181 Q0511 Q0512
L33828	10/01/2015	01/01/2024	Ostomy Supplies	A4331 A4357 A4361 A4362 A4363 A4364 A4366 A4367 A4368 A4369 A4371 A4372 A4373 A4375 A4376 A4377 A4378 A4379 A4380 A4381 A4382 A4383 A4384 A4385 A4387 A4388 A4389 A4390 A4391 A4392 A4393 A4394 A4395 A4396 A4398 A4399 A4402 A4404 A4405 A4406 and more.....
L33830	10/01/2015	05/01/2021	Pressure Reducing Support Surfaces - Group 1	A4640 A9270 E0181 E0182 E0184 E0185 E0186 E0187 E0188 E0189 E0196 E0197 E0198 E0199 E1399
L33831	10/01/2015	01/01/2024	Surgical Dressings	A4450 A4452 A4461 A4463 A4465 A4490 A4495 A4500 A4510 A4649 A6010 A6011 A6021 A6022 A6023 A6024 A6025 A6154 A6196 A6197 A6198 A6199 A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6215 A6216 A6217 A6218 A6219 A6220 and more.....
L33832	10/01/2015	01/01/2024	Tracheostomy Care Supplies	A4364 A4402 A4450 A4452 A4456 A4481 A4623 A4625 A4626 A4629 A5120 A7501 A7502 A7503 A7504 A7505 A7506 A7507 A7508 A7509 A7520 A7521 A7522 A7523 A7524 A7526 A7527
L34821	10/01/2015	01/01/2020	Transcutaneous Electrical Joint Stimulation Devices (TEJSD)	A4465 A4557 A4595 E0731 E0762
L34823	10/01/2015	01/01/2020	Tumor Treatment Field Therapy (TTFT)	A4555 E0766
L34824	10/01/2015	01/01/2020	Vacuum Erection Devices (VED)	L7900 L7902
L36267	12/01/2015	10/01/2021	Bowel Management Devices	A4335 A4337 A4453 A4458 A4459 A4520 A4553 A4554 A9270 E0275 E0276 E0350 E0352
L38953	09/05/2021	01/01/2024	Parenteral Nutrition	B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4187 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9004 B9006 B9999 E0776
L38955	09/05/2021	01/01/2024	Enteral Nutrition	A9270 B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4100 B4102 B4103 B4104 B4105 B4148 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B9002 B9998 E0776

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