CARTA CIRCULARpublicaciones.ssspr.com/Cartas/Documents/M1203073.pdf · CARTA CIRCULAR # M1203073 12...

CARTA CIRCULAR # M1203073 12 de marzo de 2012 Página 1

CARTA CIRCULAR #M1203073 12 de marzo de 2012 A: PROVEEDORES DE EQUIPO MÉDICO DURADERO DE TRIPLE-S SALUD RE: PLANES MEDICARE ADVANTAGE 2012 Saludos cordiales: Como parte de los cambios incorporados en el 2012 a los diferentes productos Medicare Advantage de Triple-S Salud, estos incluyen la aplicación de coaseguros en cierto equipo médico duradero. Por esta razón, hemos actualizado la tabla de equipo médico duradero y prótesis –específicamente en cuanto al requisito de preautorización y la asignación de coaseguro, según aplique. La asignación de los coaseguros tiene las siguientes consideraciones:

Los coaseguros no aplican a las prótesis de seno ni a los sostenes (brassieres)

Los coaseguros no aplican a los implantes

Los coaseguros sí aplican para las prótesis externas

Le solicitamos que haga referencia a los anejos incluidos. El Anejo 1 corresponde a la tabla que contiene los códigos de cubierta y los coaseguros aplicables a los beneficios de equipo médico duradero y prótesis, según el plan. El Anejo 2 incluye la lista de aquellos equipos a los cuales se les estará aplicando el coaseguro, asimismo si aplica o no el requisito de preautorización. Para beneficiar al asegurado, puede cotejar si existe alguna alternativa que no requiera desembolso. Le exhortamos a que comparta esta información con el personal de su oficina para garantizar que nuestros asegurados reciban los servicios cubiertos por el plan de Triple-S que seleccionaron. Para más detalles sobre las características de los nuevos beneficios y cómo facturarlos de acuerdo a la cubierta, refiérase a las cartas circulares enviadas previamente. Puede acceder a estas registrándose en nuestro portal www.ssspr.com o a través del SES Web. Si tiene alguna duda, puede comunicarse al 787-749-4700 o al 1-877-357-9777 (sin cargos, para llamadas de larga distancia).

http://www.ssspr.com/

CARTA CIRCULAR # M1203073 12 de marzo de 2012 Página 2

Nos sentimos honrados de contar con sus servicios y le agradecemos su continuo respaldo y colaboración a todas nuestras iniciativas de salud para beneficio de todos nuestros asegurados. Cordialmente, Yamile Suárez Gierbolini Enid M. Mateo Reyes, MD Vicepresidenta Interina Director Médico Asociado División de Programas Federales División de Gerencia Clínica Anejos

Planes Medicare Advantage 2012 Triple-S Salud

ANEJO 1 - Tabla de Códigos de Cubierta y Copagos/Coaseguros para Equipo Médico Duradero y Aparatos Prostéticos

1 Algunos servicios y procedimiento pueden necesitar una precertificación.

Triple-S Medicare OPTIMO

(PPO)


PLUS (PPO)

Triple-S Medicare OPTIMO SELECT (HMO)


PREMIER (HMO)

Triple-S Medicare OPTIMO NOVEL

(HMO POS)

Triple-S Medicare Selecto con MEDICARE PLATINO

(HMO SNP)

Triple-S Medicare Selecto con MEDICARE PLATINO 2 (HMO SNP)

Códigos de Cubiertas Ambulatorias

AF-06 AF-18 AF-38 AF-39 AF-60 Cubierta 010: AF-30

Cubierta 011: AF-89

Cubierta 010: AF-42

Cubierta 011: AF-87

Equipo Médico Duradero1

$0;

Sólo aplica 10% a los códigos de servicios

identificados en el Anejo 2

$0;



$0;



$0 10% $0;

Sólo aplica 10% a los códigos de

servicios identificados en

el Anejo 2

$0;



el Anejo 2

Aparatos Prostéticos1

10% 10% 10% 0% 10% $0;



el Anejo 2

$0;



el Anejo 2

Código ModificadorModificador

2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

Medical Surgical Supplies

A4216 NU Sterile water/saline, 10 ml

A4217 Sterile water/saline, 500 ml

A4217 AU Sterile water/saline, 500 ml

A4221 Maint drug infus cath per wk

A4222 Infusion supplies with pump

A4233 NU Alkalin batt for glucose mon

A4233 NU KL Alkalin batt for glucose mon

A4234 NU J-cell batt for glucose mon

A4234 NU KL J-cell batt for glucose mon

A4235 NU Lithium batt for glucose mon

A4235 NU KL Lithium batt for glucose mon

A4236 NU Silvr oxide batt glucose mon

A4236 NU KL Silvr oxide batt glucose mon

A4253 NU Blood glucose/reagent strips

A4253 NU KL Blood glucose/reagent strips

A4255 Glucose monitor platforms

A4256 Calibrator solution/chips

A4256 KL Calibrator solution/chips

A4257 Replace Lensshield Cartridge

A4258 Lancet device each

A4258 KL Lancet device each

A4259 Lancets per box

A4259 KL Lancets per box

A4265 Paraffin

A4280 Brst prsths adhsv attchmnt

A4310 Insert tray w/o bag/cath

A4311 Catheter w/o bag 2-way latex

A4312 Cath w/o bag 2-way silicone

A4313 Catheter w/bag 3-way

A4314 Cath w/drainage 2-way latex

A4315 Cath w/drainage 2-way silcne

A4316 Cath w/drainage 3-way

A4320 Irrigation tray

A4321 Cath therapeutic irrig agent

A4322 Irrigation syringe

A4326 Male external catheter

A4327 Fem urinary collect dev cup

A4328 Fem urinary collect pouch

A4330 Stool collection pouch

A4331 Extension drainage tubing

A4332 Lube sterile packet

A4333 Urinary cath anchor device

A4334 Urinary cath leg strap

A4336 Urethral insert

A4338 Indwelling catheter latex

A4340 Indwelling catheter special

A4344 Cath indw foley 2 way silicn

A4346 Cath indw foley 3 way

A4349 Disposable male external cat

A4351 Straight tip urine catheter

A4352 Coude tip urinary catheter

ANEJO 2 - TABLA DE EQUIPO MÉDICO DURADERO Y PRÓTESIS

Planes Medicare Advantage de Triple-S Salud

1


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

A4353 Intermittent urinary cath

A4354 Cath insertion tray w/bag

A4355 Bladder irrigation tubing

A4356 Ext ureth clmp or compr dvc

A4357 Bedside drainage bag

A4358 Urinary leg or abdomen bag

A4360 Disposable ext urethral dev

A4361 Ostomy face plate

A4362 Solid skin barrier

A4363 Ostomy clamp, replacement

A4364 Adhesive, liquid or equal

A4366 Ostomy vent

A4367 Ostomy belt

A4368 Ostomy filter

A4369 Skin barrier liquid per oz

A4371 Skin barrier powder per oz

A4372 Skin barrier solid 4x4 equiv

A4373 Skin barrier with flange

A4375 Drainable plastic pch w fcpl

A4376 Drainable rubber pch w fcplt

A4377 Drainable plstic pch w/o fp

A4378 Drainable rubber pch w/o fp

A4379 Urinary plastic pouch w fcpl

A4380 Urinary rubber pouch w fcplt

A4381 Urinary plastic pouch w/o fp

A4382 Urinary hvy plstc pch w/o fp

A4383 Urinary rubber pouch w/o fp

A4384 Ostomy faceplt/silicone ring

A4385 Ost skn barrier sld ext wear

A4387 Ost clsd pouch w att st barr

A4388 Drainable pch w ex wear barr

A4389 Drainable pch w st wear barr

A4390 Drainable pch ex wear convex

A4391 Urinary pouch w ex wear barr

A4392 Urinary pouch w st wear barr

A4393 Urine pch w ex wear bar conv

A4394 Ostomy pouch liq deodorant

A4395 Ostomy pouch solid deodorant

A4396 Peristomal hernia supprt blt

A4397 Irrigation supply sleeve

A4398 Ostomy irrigation bag

A4399 Ostomy irrig cone/cath w brs

A4400 Ostomy irrigation set

A4402 Lubricant per ounce

A4404 Ostomy ring each

A4405 Nonpectin based ostomy paste

A4406 Pectin based ostomy paste

A4407 Ext wear ost skn barr <=4sq"

A4408 Ext wear ost skn barr >4sq"

A4409 Ost skn barr convex <=4 sq i

A4410 Ost skn barr extnd >4 sq

A4411 Ost skn barr extnd =4sq

A4412 Ost pouch drain high output

A4413 2 pc drainable ost pouch

A4414 Ost sknbar w/o conv<=4 sq in

A4415 Ost skn barr w/o conv >4 sqi

2


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

A4416 Ost pch clsd w barrier/filtr

A4417 Ost pch w bar/bltinconv/fltr

A4418 Ost pch clsd w/o bar w filtr

A4419 Ost pch for bar w flange/flt

A4420 Ost pch clsd for bar w lk fl

A4421 NU Ostomy supply

A4422 Ost pouch absorbent material

A4423 Ost pch for bar w lk fl/fltr

A4424 Ost pch drain w bar & filter

A4425 Ost pch drain for barrier fl

A4426 Ost pch drain 2 piece system

A4427 Ost pch drain/barr lk flng/f

A4428 Urine ost pouch w faucet/tap

A4429 Urine ost pouch w bltinconv

A4430 Ost urine pch w b/bltin conv

A4431 Ost pch urine w barrier/tapv

A4432 Os pch urine w bar/fange/tap

A4433 Urine ost pch bar w lock fln

A4434 Ost pch urine w lock flng/ft

A4450 AU Non-waterproof tape

A4450 AV Non-waterproof tape

A4450 AW Non-waterproof tape

A4452 AU Waterproof tape

A4452 AV Waterproof tape

A4452 AW Waterproof tape

A4455 Adhesive remover per ounce

A4456 Adhesive remover, wipes

A4461 Surgicl dress hold non-reuse

A4463 Surgical dress holder reuse

A4481 Tracheostoma filter

A4483 Moisture exchanger

A4556 Electrodes, pair

A4557 Lead wires, pair

A4558 Conductive gel or paste

A4559 Coupling gel or paste

A4561 Pessary rubber, any type

A4562 Pessary, non rubber,any type

A4595 TENS suppl 2 lead per month

A4604 NU Tubing with heating element

A4605 NU Trach suction cath close sys

A4608 Transtracheal oxygen cath

A4611 NU Heavy duty battery

A4611 RR Heavy duty battery

A4611 UE Heavy duty battery

A4612 NU Battery cables

A4612 RR Battery cables

A4612 UE Battery cables

A4613 NU Battery charger

A4613 RR Battery charger

A4613 UE Battery charger

A4614 Hand-held PEFR meter

A4615 Cannula nasal

A4616 Tubing (oxygen) per foot

A4617 Mouth piece

A4618 NU Breathing circuits

A4618 RR Breathing circuits

3


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

A4618 UE Breathing circuits

A4619 NU Face tent

A4620 Variable concentration mask

A4623 Tracheostomy inner cannula

A4624 NU Tracheal suction tube

A4625 Trach care kit for new trach

A4626 Tracheostomy cleaning brush

A4628 NU Oropharyngeal suction cath

A4629 Tracheostomy care kit

A4630 NU Repl bat t.e.n.s. own by pt

A4633 NU Uvl replacement bulb

A4635 NU Underarm crutch pad

A4635 RR Underarm crutch pad

A4635 UE Underarm crutch pad

A4636 NU Handgrip for cane etc

A4636 NU KE Handgrip for cane etc

A4636 RR Handgrip for cane etc

A4636 RR KE Handgrip for cane etc

A4636 UE Handgrip for cane etc

A4636 UE KE Handgrip for cane etc

A4637 NU Repl tip cane/crutch/walker

A4637 NU KE Repl tip cane/crutch/walker

A4637 RR Repl tip cane/crutch/walker

A4637 RR KE Repl tip cane/crutch/walker

A4637 UE Repl tip cane/crutch/walker

A4637 UE KE Repl tip cane/crutch/walker

A4638 NU Repl batt pulse gen sys

A4638 RR Repl batt pulse gen sys

A4638 UE Repl batt pulse gen sys

A4639 NU Infrared ht sys replcmnt pad

A4640 NU Alternating pressure pad

A4640 RR Alternating pressure pad

A4640 UE Alternating pressure pad

A5051 Pouch clsd w barr attached

A5052 Clsd ostomy pouch w/o barr

A5053 Clsd ostomy pouch faceplate

A5054 Clsd ostomy pouch w/flange

A5055 Stoma cap

A5061 Pouch drainable w barrier at

A5062 Drnble ostomy pouch w/o barr

A5063 Drain ostomy pouch w/flange

A5071 Urinary pouch w/barrier

A5072 Urinary pouch w/o barrier

A5073 Urinary pouch on barr w/flng

A5081 Continent stoma plug

A5082 Continent stoma catheter

A5083 Stoma absorptive cover

A5093 Ostomy accessory convex inse

A5102 Bedside drain btl w/wo tube

A5105 Urinary suspensory

A5112 Urinary leg bag

A5113 Latex leg strap

A5114 Foam/fabric leg strap

A5120 AU Skin barrier, wipe or swab

A5120 AV Skin barrier, wipe or swab

A5121 Solid skin barrier 6x6

4


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

A5122 Solid skin barrier 8x8

A5126 Disk/foam pad +or- adhesive

A5131 Appliance cleaner

A5200 Percutaneous catheter anchor

A5500 Diab shoe for density insert

A5501 Diabetic custom molded shoe

A5503 Diabetic shoe w/roller/rockr

A5504 Diabetic shoe with wedge

A5505 Diab shoe w/metatarsal bar

A5506 Diabetic shoe w/off set heel

A5507 Modification diabetic shoe

A5512 Multi den insert direct form

A5513 Multi den insert custom mold

A6010 Collagen based wound filler

A6011 Collagen gel/paste wound fil

A6021 Collagen dressing <=16 sq in

A6022 Collagen drsg>16<=48 sq in

A6023 Collagen dressing >48 sq in

A6024 Collagen dsg wound filler

A6154 Wound pouch each

A6196 Alginate dressing <=16 sq in

A6197 Alginate drsg >16 <=48 sq in

A6199 Alginate drsg wound filler

A6203 Composite drsg <= 16 sq in

A6204 Composite drsg >16<=48 sq in

A6207 Contact layer >16<= 48 sq in

A6209 Foam drsg <=16 sq in w/o bdr

A6210 Foam drg >16<=48 sq in w/o b

A6211 Foam drg > 48 sq in w/o brdr

A6212 Foam drg <=16 sq in w/border

A6214 Foam drg > 48 sq in w/border

A6216 Non-sterile gauze<=16 sq in

A6217 Non-sterile gauze>16<=48 sq

A6219 Gauze <= 16 sq in w/border

A6220 Gauze >16 <=48 sq in w/bordr

A6222 Gauze <=16 in no w/sal w/o b

A6223 Gauze >16<=48 no w/sal w/o b

A6224 Gauze > 48 in no w/sal w/o b

A6229 Gauze >16<=48 sq in watr/sal

A6231 Hydrogel dsg<=16 sq in

A6232 Hydrogel dsg>16<=48 sq in

A6233 Hydrogel dressing >48 sq in

A6234 Hydrocolld drg <=16 w/o bdr

A6235 Hydrocolld drg >16<=48 w/o b

A6236 Hydrocolld drg > 48 in w/o b

A6237 Hydrocolld drg <=16 in w/bdr

A6238 Hydrocolld drg >16<=48 w/bdr

A6240 Hydrocolld drg filler paste

A6241 Hydrocolloid drg filler dry

A6242 Hydrogel drg <=16 in w/o bdr

A6243 Hydrogel drg >16<=48 w/o bdr

A6244 Hydrogel drg >48 in w/o bdr

A6245 Hydrogel drg <= 16 in w/bdr

A6246 Hydrogel drg >16<=48 in w/b

A6247 Hydrogel drg > 48 sq in w/b

A6248 Hydrogel drsg gel filler

5


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

A6251 Absorpt drg <=16 sq in w/o b

A6252 Absorpt drg >16 <=48 w/o bdr

A6253 Absorpt drg > 48 sq in w/o b

A6254 Absorpt drg <=16 sq in w/bdr

A6255 Absorpt drg >16<=48 in w/bdr

A6257 Transparent film <= 16 sq in

A6258 Transparent film >16<=48 in

A6259 Transparent film > 48 sq in

A6266 Impreg gauze no h20/sal/yard

A6402 Sterile gauze <= 16 sq in

A6403 Sterile gauze>16 <= 48 sq in

A6407 Packing strips, non-impreg

A6410 Sterile eye pad

A6411 Non-sterile eye pad

A6441 Pad band w>=3" <5"/yd

A6442 Conform band n/s w<3"/yd

A6443 Conform band n/s w>=3"<5"/yd

A6444 Conform band n/s w>=5"/yd

A6445 Conform band s w <3"/yd

A6446 Conform band s w>=3" <5"/yd

A6447 Conform band s w >=5"/yd

A6448 Lt compres band <3"/yd

A6449 Lt compres band >=3" <5"/yd

A6450 Lt compres band >=5"/yd

A6451 Mod compres band w>=3"<5"/yd

A6452 High compres band w>=3"<5"yd

A6453 Self-adher band w <3"/yd

A6454 Self-adher band w>=3" <5"/yd

A6455 Self-adher band >=5"/yd

A6456 Zinc paste band w >=3"<5"/yd

A6457 Tubular dressing

A6501 Compres burngarment bodysuit

A6502 Compres burngarment chinstrp

A6503 Compres burngarment facehood

A6504 Cmprsburngarment glove-wrist

A6505 Cmprsburngarment glove-elbow

A6506 Cmprsburngrmnt glove-axilla

A6507 Cmprs burngarment foot-knee

A6508 Cmprs burngarment foot-thigh

A6509 Compres burn garment jacket

A6510 Compres burn garment leotard

A6511 Compres burn garment panty

A6513 Compress burn mask face/neck

A6531 AW Compression stocking BK30-40

A6532 AW Compression stocking BK40-50

A6545 Grad comp non-elastic BK

A6545 AW Grad comp non-elastic BK

A6550 Neg pres wound ther drsg set

A7000 NU Disposable canister for pump

A7000 NU KE Disposable canister for pump

A7001 NU Nondisposable pump canister

A7002 NU Tubing used w suction pump

A7003 NU Nebulizer administration set

A7004 NU Disposable nebulizer sml vol

A7005 NU Nondisposable nebulizer set

A7006 NU Filtered nebulizer admin set

6


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

A7007 NU Lg vol nebulizer disposable

A7008 NU Disposable nebulizer prefill

A7009 NU Nebulizer reservoir bottle

A7010 NU Disposable corrugated tubing

A7012 NU Nebulizer water collec devic

A7013 NU Disposable compressor filter

A7014 NU Compressor nondispos filter

A7015 NU Aerosol mask used w nebulize

A7016 NU Nebulizer dome & mouthpiece

A7017 NU Nebulizer not used w oxygen

A7017 RR Nebulizer not used w oxygen

A7017 UE Nebulizer not used w oxygen

A7018 Water distilled w/nebulizer

A7020 NU Interface, cough stim device

A7025 NU Replace chest compress vest

A7026 NU Replace chst cmprss sys hose

A7027 NU Combination oral/nasal mask

A7028 NU Repl oral cushion combo mask

A7029 NU Repl nasal pillow comb mask

A7030 NU CPAP full face mask

A7031 NU Replacement facemask interfa

A7032 NU Replacement nasal cushion

A7033 NU Replacement nasal pillows

A7034 NU Nasal application device

A7035 NU Pos airway press headgear

A7036 NU Pos airway press chinstrap

A7037 NU Pos airway pressure tubing

A7038 NU Pos airway pressure filter

A7039 NU Filter, non disposable w pap

A7040 One way chest drain valve

A7041 Water seal drain container

A7042 Implanted pleural catheter

A7043 Vacuum drainagebottle/tubing

A7044 NU PAP oral interface

A7045 NU Repl exhalation port for PAP

A7045 RR Repl exhalation port for PAP

A7045 UE Repl exhalation port for PAP

A7046 NU Repl water chamber, PAP dev

A7501 Tracheostoma valve w diaphra

A7502 Replacement diaphragm/fplate

A7503 HMES filter holder or cap

A7504 Tracheostoma HMES filter

A7505 HMES or trach valve housing

A7506 HMES/trachvalve adhesivedisk

A7507 Integrated filter & holder

A7508 Housing & Integrated Adhesiv

A7509 Heat & moisture exchange sys

A7520 Trach/laryn tube non-cuffed

A7521 Trach/laryn tube cuffed

A7522 Trach/laryn tube stainless

A7524 Tracheostoma stent/stud/bttn

A7525 Tracheostomy mask

A7526 Tracheostomy tube collar

A7527 Trach/laryn tube plug/stop

A8000 NU Soft protect helmet prefab

A8000 RR Soft protect helmet prefab

7


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

A8000 UE Soft protect helmet prefab

A8001 NU Hard protect helmet prefab

A8001 RR Hard protect helmet prefab

A8001 UE Hard protect helmet prefab

A8002 NU Soft protect helmet custom

A8002 RR Soft protect helmet custom

A8002 UE Soft protect helmet custom

A8003 NU Hard protect helmet custom

A8003 RR Hard protect helmet custom

A8003 UE Hard protect helmet custom

A8004 NU Repl soft interface, helmet

A8004 RR Repl soft interface, helmet

A8004 UE Repl soft interface, helmet

Durable Medical Equipment

E0100 NU Cane adjust/fixed with tip

E0100 RR Cane adjust/fixed with tip

E0100 UE Cane adjust/fixed with tip

E0105 NU Cane adjust/fixed quad/3 pro

E0105 RR Cane adjust/fixed quad/3 pro

E0105 UE Cane adjust/fixed quad/3 pro

E0110 NU Crutch forearm pair

E0110 RR Crutch forearm pair

E0110 UE Crutch forearm pair

E0111 NU Crutch forearm each

E0111 RR Crutch forearm each

E0111 UE Crutch forearm each

E0112 NU Crutch underarm pair wood

E0112 RR Crutch underarm pair wood

E0112 UE Crutch underarm pair wood

E0113 NU Crutch underarm each wood

E0113 RR Crutch underarm each wood

E0113 UE Crutch underarm each wood

E0114 NU Crutch underarm pair no wood

E0114 RR Crutch underarm pair no wood

E0114 UE Crutch underarm pair no wood

E0116 NU Crutch underarm each no wood

E0116 RR Crutch underarm each no wood

E0116 UE Crutch underarm each no wood

E0117 NU Underarm springassist crutch

E0117 RR Underarm springassist crutch

E0117 UE Underarm springassist crutch

E0130 NU Walker rigid adjust/fixed ht

E0130 RR Walker rigid adjust/fixed ht

E0130 UE Walker rigid adjust/fixed ht

E0135 NU Walker folding adjust/fixed

E0135 RR Walker folding adjust/fixed

E0135 UE Walker folding adjust/fixed

E0140 NU Walker w trunk support

E0140 RR Walker w trunk support

E0140 UE Walker w trunk support

E0141 NU Rigid wheeled walker adj/fix

E0141 RR Rigid wheeled walker adj/fix

E0141 UE Rigid wheeled walker adj/fix

E0143 NU Walker folding wheeled w/o s

E0143 RR Walker folding wheeled w/o s

E0143 UE Walker folding wheeled w/o s

8


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0144 NU Enclosed walker w rear seat

E0144 RR Enclosed walker w rear seat

E0144 UE Enclosed walker w rear seat

E0147 NU Walker variable wheel resist

E0147 RR Walker variable wheel resist

E0147 UE Walker variable wheel resist

E0148 NU Heavyduty walker no wheels

E0148 RR Heavyduty walker no wheels

E0148 UE Heavyduty walker no wheels

E0149 NU Heavy duty wheeled walker

E0149 RR Heavy duty wheeled walker

E0149 UE Heavy duty wheeled walker

E0153 NU Forearm crutch platform atta

E0153 RR Forearm crutch platform atta

E0153 UE Forearm crutch platform atta

E0154 NU Walker platform attachment

E0154 RR Walker platform attachment

E0154 UE Walker platform attachment

E0155 NU Walker wheel attachment,pair

E0155 RR Walker wheel attachment,pair

E0155 UE Walker wheel attachment,pair

E0156 NU Walker seat attachment

E0156 RR Walker seat attachment

E0156 UE Walker seat attachment

E0157 NU Walker crutch attachment

E0157 RR Walker crutch attachment

E0157 UE Walker crutch attachment

E0158 NU Walker leg extenders set of4

E0158 RR Walker leg extenders set of4

E0158 UE Walker leg extenders set of4

E0159 NU Brake for wheeled walker

E0159 RR Brake for wheeled walker

E0159 UE Brake for wheeled walker

E0160 NU Sitz type bath or equipment

E0160 RR Sitz type bath or equipment

E0160 UE Sitz type bath or equipment

E0161 NU Sitz bath/equipment w/faucet

E0161 RR Sitz bath/equipment w/faucet

E0161 UE Sitz bath/equipment w/faucet

E0162 NU Sitz bath chair

E0162 RR Sitz bath chair

E0162 UE Sitz bath chair

E0163 NU Commode chair with fixed arm

E0163 RR Commode chair with fixed arm

E0163 UE Commode chair with fixed arm

E0165 RR Commode chair with detacharm

E0167 NU Commode chair pail or pan

E0167 RR Commode chair pail or pan

E0167 UE Commode chair pail or pan

E0168 NU Heavyduty/wide commode chair

E0168 RR Heavyduty/wide commode chair

E0168 UE Heavyduty/wide commode chair

E0170 RR Commode chair electric

E0171 RR Commode chair non-electric

E0175 NU Commode chair foot rest

E0175 RR Commode chair foot rest

9


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0175 UE Commode chair foot rest

E0181 RR Press pad alternating w/ pum

E0182 RR Replace pump, alt press pad

E0184 NU Dry pressure mattress

E0184 RR Dry pressure mattress

E0184 UE Dry pressure mattress

E0185 NU Gel pressure mattress pad

E0185 RR Gel pressure mattress pad

E0185 UE Gel pressure mattress pad

E0186 RR Air pressure mattress

E0187 RR Water pressure mattress

E0188 NU Synthetic sheepskin pad

E0188 RR Synthetic sheepskin pad

E0188 UE Synthetic sheepskin pad

E0189 NU Lambswool sheepskin pad

E0189 RR Lambswool sheepskin pad

E0189 UE Lambswool sheepskin pad

E0191 NU Protector heel or elbow

E0191 RR Protector heel or elbow

E0191 UE Protector heel or elbow

E0193 RR Powered air flotation bed

E0194 RR Air fluidized bed

E0196 RR Gel pressure mattress

E0197 NU Air pressure pad for mattres

E0197 RR Air pressure pad for mattres

E0197 UE Air pressure pad for mattres

E0198 NU Water pressure pad for mattr

E0198 RR Water pressure pad for mattr

E0198 UE Water pressure pad for mattr

E0199 NU Dry pressure pad for mattres

E0199 RR Dry pressure pad for mattres

E0199 UE Dry pressure pad for mattres

E0200 NU Heat lamp without stand

E0200 RR Heat lamp without stand

E0200 UE Heat lamp without stand

E0202 RR Phototherapy light w/ photom

E0205 NU Heat lamp with stand

E0205 RR Heat lamp with stand

E0205 UE Heat lamp with stand

E0210 NU Electric heat pad standard

E0210 RR Electric heat pad standard

E0210 UE Electric heat pad standard

E0215 NU Electric heat pad moist

E0215 RR Electric heat pad moist

E0215 UE Electric heat pad moist

E0217 NU Water circ heat pad w pump

E0217 RR Water circ heat pad w pump

E0217 UE Water circ heat pad w pump

E0225 NU Hydrocollator unit

E0225 RR Hydrocollator unit

E0225 UE Hydrocollator unit

E0235 RR Paraffin bath unit portable

E0236 RR Pump for water circulating p

E0239 NU Hydrocollator unit portable

E0239 RR Hydrocollator unit portable

E0239 UE Hydrocollator unit portable

10


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0249 NU Pad water circulating heat u

E0249 RR Pad water circulating heat u

E0249 UE Pad water circulating heat u

E0250 RR Hosp bed fixed ht w/ mattres X X

E0251 RR Hosp bed fixd ht w/o mattres X X

E0255 RR Hospital bed var ht w/ mattr X X

E0256 RR Hospital bed var ht w/o matt X X

E0260 RR Hosp bed semi-electr w/ matt X X

E0261 RR Hosp bed semi-electr w/o mat X X

E0265 RR Hosp bed total electr w/ mat X X

E0266 RR Hosp bed total elec w/o matt X X

E0271 NU Mattress innerspring X X

E0271 RR Mattress innerspring X X

E0271 UE Mattress innerspring X X

E0272 NU Mattress foam rubber X X

E0272 RR Mattress foam rubber X X

E0272 UE Mattress foam rubber X X

E0275 NU Bed pan standard

E0275 RR Bed pan standard

E0275 UE Bed pan standard

E0276 NU Bed pan fracture

E0276 RR Bed pan fracture

E0276 UE Bed pan fracture

E0277 RR Powered pres-redu air mattrs X X

E0280 NU Bed cradle

E0280 RR Bed cradle

E0280 UE Bed cradle

E0290 RR Hosp bed fx ht w/o rails w/m X X

E0291 RR Hosp bed fx ht w/o rail w/o X X

E0292 RR Hosp bed var ht w/o rail w/o X X

E0293 RR Hosp bed var ht w/o rail w/ X X

E0294 RR Hosp bed semi-elect w/ mattr X X

E0295 RR Hosp bed semi-elect w/o matt X X

E0296 RR Hosp bed total elect w/ matt no cubierto no cubierto

E0297 RR Hosp bed total elect w/o mat no cubierto no cubierto

E0300 NU Enclosed ped crib hosp grade

E0300 RR Enclosed ped crib hosp grade

E0300 UE Enclosed ped crib hosp grade

E0301 RR HD hosp bed, 350-600 lbs X X

E0302 RR Ex hd hosp bed > 600 lbs X X

E0303 RR Hosp bed hvy dty xtra wide X X

E0304 RR Hosp bed xtra hvy dty x wide X X

E0305 RR Rails bed side half length X X

E0310 NU Rails bed side full length X X

E0310 RR Rails bed side full length X X

E0310 UE Rails bed side full length X X

E0316 RR Bed safety enclosure X X

E0325 NU Urinal male jug-type

E0325 RR Urinal male jug-type

E0325 UE Urinal male jug-type

E0326 NU Urinal female jug-type

E0326 RR Urinal female jug-type

E0326 UE Urinal female jug-type

E0371 RR Nonpower mattress overlay X X

E0372 RR Powered air mattress overlay X X

E0373 RR Nonpowered pressure mattress X X

11


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0424 RR Stationary compressed gas 02 X

E0431 RR Portable gaseous 02 X

E0433 RR Portable liquid oxygen sys X

E0434 RR Portable liquid 02 X

E0439 RR Stationary liquid 02 X

E0441 Stationary O2 contents, gas X

E0442 Stationary O2 contents, liq X

E0443 Portable 02 contents, gas X

E0444 Portable 02 contents, liquid X

E0445 Oximeter device for measuring blood oxygen levels X

E0450 RR Vol control vent invasiv int X

E0457 NU Chest shell X X

E0457 RR Chest shell X X

E0457 UE Chest shell X X

E0459 RR Chest wrap X X

E0460 RR Neg press vent portabl/statn X X

E0461 RR Vol control vent noninv int X X

E0462 RR Rocking bed w/ or w/o side r X X

E0463 RR Press supp vent invasive int X

E0464 RR Press supp vent noninv int X

E0470 RR RAD w/o backup non-inv intfc X

E0471 RR RAD w/backup non inv intrfc X

E0472 RR RAD w backup invasive intrfc X

E0480 RR Percussor elect/pneum home m X

E0482 RR Cough stimulating device X

E0483 RR Chest compression gen system X

E0484 NU Non-elec oscillatory pep dvc X

E0484 RR Non-elec oscillatory pep dvc X

E0484 UE Non-elec oscillatory pep dvc X

E0485 NU Oral device/appliance prefab no cubierto no cubierto

E0485 RR Oral device/appliance prefab no cubierto no cubierto

E0485 UE Oral device/appliance prefab no cubierto no cubierto

E0486 NU Oral device/appliance cusfab no cubierto no cubierto

E0486 RR Oral device/appliance cusfab no cubierto no cubierto

E0486 UE Oral device/appliance cusfab no cubierto no cubierto

E0500 RR Ippb all types

E0550 RR Humidif extens supple w ippb

E0560 NU Humidifier supplemental w/ i

E0560 RR Humidifier supplemental w/ i

E0560 UE Humidifier supplemental w/ i

E0561 NU Humidifier nonheated w PAP

E0561 RR Humidifier nonheated w PAP

E0561 UE Humidifier nonheated w PAP

E0562 NU Humidifier heated used w PAP

E0562 RR Humidifier heated used w PAP

E0562 UE Humidifier heated used w PAP

E0565 RR Compressor air power source

E0570 RR Nebulizer with compression

E0571 RR Aerosol compressor for svneb

E0572 RR Aerosol compressor adjust pr

E0574 RR Ultrasonic generator w svneb

E0575 RR Nebulizer ultrasonic

E0580 NU Nebulizer for use w/ regulat

E0580 RR Nebulizer for use w/ regulat

E0580 UE Nebulizer for use w/ regulat

E0585 RR Nebulizer w/ compressor & he

12


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0600 NU Suction pump portab hom modl

E0600 RR Suction pump portab hom modl

E0601 NU Cont airway pressure device

E0601 RR Cont airway pressure device

E0602 NU Manual breast pump

E0602 RR Manual breast pump

E0602 UE Manual breast pump

E0605 NU Vaporizer room type

E0605 RR Vaporizer room type

E0605 UE Vaporizer room type

E0606 RR Drainage board postural

E0607 NU Blood glucose monitor home

E0607 RR Blood glucose monitor home

E0607 UE Blood glucose monitor home

E0610 NU Pacemaker monitr audible/vis

E0610 RR Pacemaker monitr audible/vis

E0610 UE Pacemaker monitr audible/vis

E0615 NU Pacemaker monitr digital/vis

E0615 RR Pacemaker monitr digital/vis

E0615 UE Pacemaker monitr digital/vis

E0617 RR Automatic ext defibrillator

E0617 RR KF Automatic ext defibrillator

E0618 RR Apnea monitor

E0619 RR Apnea monitor w recorder

E0620 NU Cap bld skin piercing laser

E0620 RR Cap bld skin piercing laser

E0620 UE Cap bld skin piercing laser

E0621 NU Patient lift sling or seat

E0621 RR Patient lift sling or seat

E0621 UE Patient lift sling or seat

E0627 NU Seat lift incorp lift-chair

E0627 RR Seat lift incorp lift-chair

E0627 UE Seat lift incorp lift-chair

E0628 NU Seat lift for pt furn-electr

E0628 RR Seat lift for pt furn-electr

E0628 UE Seat lift for pt furn-electr

E0629 NU Seat lift for pt furn-non-el

E0629 RR Seat lift for pt furn-non-el

E0629 UE Seat lift for pt furn-non-el

E0630 NU Patient lift hydraulic

E0630 RR Patient lift hydraulic

E0635 RR Patient lift electric

E0636 RR PT support & positioning sys

E0650 NU Pneuma compresor non-segment

E0650 RR Pneuma compresor non-segment

E0650 UE Pneuma compresor non-segment

E0651 NU Pneum compressor segmental

E0651 RR Pneum compressor segmental

E0651 UE Pneum compressor segmental

E0652 NU Pneum compres w/cal pressure

E0652 RR Pneum compres w/cal pressure

E0652 UE Pneum compres w/cal pressure

E0655 NU Pneumatic appliance half arm

E0655 RR Pneumatic appliance half arm

E0655 UE Pneumatic appliance half arm

E0656 NU Segmental pneumatic trunk

13


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0656 RR Segmental pneumatic trunk

E0656 UE Segmental pneumatic trunk

E0657 NU Segmental pneumatic chest

E0657 RR Segmental pneumatic chest

E0657 UE Segmental pneumatic chest

E0660 NU Pneumatic appliance full leg

E0660 RR Pneumatic appliance full leg

E0660 UE Pneumatic appliance full leg

E0665 NU Pneumatic appliance full arm

E0665 RR Pneumatic appliance full arm

E0665 UE Pneumatic appliance full arm

E0666 NU Pneumatic appliance half leg

E0666 RR Pneumatic appliance half leg

E0666 UE Pneumatic appliance half leg

E0667 NU Seg pneumatic appl full leg

E0667 RR Seg pneumatic appl full leg

E0667 UE Seg pneumatic appl full leg

E0668 NU Seg pneumatic appl full arm

E0668 RR Seg pneumatic appl full arm

E0668 UE Seg pneumatic appl full arm

E0669 NU Seg pneumatic appli half leg

E0669 RR Seg pneumatic appli half leg

E0669 UE Seg pneumatic appli half leg

E0671 NU Pressure pneum appl full leg

E0671 RR Pressure pneum appl full leg

E0671 UE Pressure pneum appl full leg

E0672 NU Pressure pneum appl full arm

E0672 RR Pressure pneum appl full arm

E0672 UE Pressure pneum appl full arm

E0673 NU Pressure pneum appl half leg

E0673 RR Pressure pneum appl half leg

E0673 UE Pressure pneum appl half leg

E0675 RR Pneumatic compression device

E0691 NU Uvl pnl 2 sq ft or less

E0691 RR Uvl pnl 2 sq ft or less

E0691 UE Uvl pnl 2 sq ft or less

E0692 NU Uvl sys panel 4 ft

E0692 RR Uvl sys panel 4 ft

E0692 UE Uvl sys panel 4 ft

E0693 NU Uvl sys panel 6 ft

E0693 RR Uvl sys panel 6 ft

E0693 UE Uvl sys panel 6 ft

E0694 NU Uvl md cabinet sys 6 ft

E0694 RR Uvl md cabinet sys 6 ft

E0694 UE Uvl md cabinet sys 6 ft

E0705 NU Transfer device

E0705 RR Transfer device

E0705 UE Transfer device

E0720 NU Tens two lead

E0730 NU Tens four lead

E0731 NU Conductive garment for tens/

E0740 NU Incontinence treatment systm

E0740 RR Incontinence treatment systm

E0740 UE Incontinence treatment systm

E0744 RR Neuromuscular stim for scoli

E0745 RR Neuromuscular stim for shock

14


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0747 NU KF Elec osteogen stim not spine X

E0747 RR KF Elec osteogen stim not spine X

E0747 UE KF Elec osteogen stim not spine X

E0748 NU KF Elec osteogen stim spinal X

E0748 RR KF Elec osteogen stim spinal X

E0748 UE KF Elec osteogen stim spinal X

E0749 RR KF Elec osteogen stim implanted X

E0760 NU KF Osteogen ultrasound stimltor X

E0760 RR KF Osteogen ultrasound stimltor X

E0760 UE KF Osteogen ultrasound stimltor X

E0762 NU Trans elec jt stim dev sys

E0762 RR Trans elec jt stim dev sys

E0762 UE Trans elec jt stim dev sys

E0764 NU KF Functional neuromuscularstim X

E0764 RR KF Functional neuromuscularstim X

E0764 UE KF Functional neuromuscularstim X

E0765 NU Nerve stimulator for tx n&v

E0765 RR Nerve stimulator for tx n&v

E0765 UE Nerve stimulator for tx n&v

E0776 NU Iv pole

E0776 RR Iv pole

E0776 UE Iv pole

E0779 RR Amb infusion pump mechanical X

E0780 NU Mech amb infusion pump <8hrs X

E0781 RR External ambulatory infus pu X

E0782 NU KF Non-programble infusion pump X

E0782 RR KF Non-programble infusion pump X

E0782 UE KF Non-programble infusion pump X

E0783 NU KF Programmable infusion pump X

E0783 RR KF Programmable infusion pump X

E0783 UE KF Programmable infusion pump X

E0784 RR Ext amb infusn pump insulin X

E0785 KF Replacement impl pump cathet X

E0786 NU KF Implantable pump replacement X

E0786 RR KF Implantable pump replacement X

E0786 UE KF Implantable pump replacement X

E0791 RR Parenteral infusion pump sta

E0840 NU Tract frame attach headboard X

E0840 RR Tract frame attach headboard X

E0840 UE Tract frame attach headboard X

E0849 NU Cervical pneum trac equip X

E0849 RR Cervical pneum trac equip X

E0849 UE Cervical pneum trac equip X

E0850 NU Traction stand free standing X

E0850 RR Traction stand free standing X

E0850 UE Traction stand free standing X

E0855 NU Cervical traction equipment X

E0855 RR Cervical traction equipment X

E0855 UE Cervical traction equipment X

E0856 NU Cervic collar w air bladder X

E0856 RR Cervic collar w air bladder X

E0856 UE Cervic collar w air bladder X

E0860 NU Tract equip cervical tract X

E0860 RR Tract equip cervical tract X

E0860 UE Tract equip cervical tract X

E0870 NU Tract frame attach footboard X

15


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0870 RR Tract frame attach footboard X

E0870 UE Tract frame attach footboard X

E0880 NU Trac stand free stand extrem X

E0880 RR Trac stand free stand extrem X

E0880 UE Trac stand free stand extrem X

E0890 NU Traction frame attach pelvic X

E0890 RR Traction frame attach pelvic X

E0890 UE Traction frame attach pelvic X

E0900 NU Trac stand free stand pelvic X

E0900 RR Trac stand free stand pelvic X

E0900 UE Trac stand free stand pelvic X

E0910 RR Trapeze bar attached to bed X

E0911 RR HD trapeze bar attach to bed X

E0912 RR HD trapeze bar free standing X

E0920 RR Fracture frame attached to b X

E0930 RR Fracture frame free standing X

E0935 RR Cont pas motion exercise dev X

E0940 RR Trapeze bar free standing X

E0941 RR Gravity assisted traction de X

E0942 NU Cervical head harness/halter X

E0942 RR Cervical head harness/halter X

E0942 UE Cervical head harness/halter X

E0944 NU Pelvic belt/harness/boot X

E0944 RR Pelvic belt/harness/boot X

E0944 UE Pelvic belt/harness/boot X

E0945 NU Belt/harness extremity X

E0945 RR Belt/harness extremity X

E0945 UE Belt/harness extremity X

E0946 RR Fracture frame dual w cross X

E0947 NU Fracture frame attachmnts pe X

E0947 RR Fracture frame attachmnts pe X

E0947 UE Fracture frame attachmnts pe X

E0948 NU Fracture frame attachmnts ce X

E0948 RR Fracture frame attachmnts ce X

E0948 UE Fracture frame attachmnts ce X

E0950 NU Wheelchair accesory, tray X

E0950 NU KE Wheelchair accesory, tray X

E0950 RR Wheelchair accesory, tray X

E0950 RR KE Wheelchair accesory, tray X

E0950 UE Wheelchair accesory, tray X

E0950 UE KE Wheelchair accesory, tray X

E0951 NU Loop heel X

E0951 NU KE Loop heel X

E0951 RR Loop heel X

E0951 RR KE Loop heel

E0951 UE Loop heel

E0951 UE KE Loop heel

E0952 NU Toe loop/holder, each

E0952 NU KE Toe loop/holder, each

E0952 RR Toe loop/holder, each

E0952 RR KE Toe loop/holder, each

E0952 UE Toe loop/holder, each

E0952 UE KE Toe loop/holder, each

E0955 NU Cushioned headrest

E0955 NU KE Cushioned headrest

E0955 RR Cushioned headrest

16


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0955 RR KE Cushioned headrest

E0955 UE Cushioned headrest

E0955 UE KE Cushioned headrest

E0956 NU W/c lateral trunk/hip suppor

E0956 NU KE W/c lateral trunk/hip suppor

E0956 RR W/c lateral trunk/hip suppor

E0956 RR KE W/c lateral trunk/hip suppor

E0956 UE W/c lateral trunk/hip suppor

E0956 UE KE W/c lateral trunk/hip suppor

E0957 NU W/c medial thigh support

E0957 NU KE W/c medial thigh support

E0957 RR W/c medial thigh support

E0957 RR KE W/c medial thigh support

E0957 UE W/c medial thigh support

E0957 UE KE W/c medial thigh support

E0958 RR Whlchr att- conv 1 arm drive

E0959 NU Amputee adapter

E0959 RR Amputee adapter

E0959 UE Amputee adapter

E0960 NU W/c shoulder harness/straps

E0960 NU KE W/c shoulder harness/straps

E0960 RR W/c shoulder harness/straps

E0960 RR KE W/c shoulder harness/straps

E0960 UE W/c shoulder harness/straps

E0960 UE KE W/c shoulder harness/straps

E0961 NU Wheelchair brake extension

E0961 RR Wheelchair brake extension

E0961 UE Wheelchair brake extension

E0966 NU Wheelchair head rest extensi

E0966 RR Wheelchair head rest extensi

E0966 UE Wheelchair head rest extensi

E0967 NU Manual wc hand rim w project

E0967 RR Manual wc hand rim w project

E0967 UE Manual wc hand rim w project

E0968 RR Wheelchair commode seat

E0969 NU Wheelchair narrowing device

E0969 RR Wheelchair narrowing device

E0969 UE Wheelchair narrowing device

E0971 NU Wheelchair anti-tipping devi

E0971 RR Wheelchair anti-tipping devi

E0971 UE Wheelchair anti-tipping devi

E0973 NU W/Ch access det adj armrest

E0973 NU KE W/Ch access det adj armrest

E0973 RR W/Ch access det adj armrest

E0973 RR KE W/Ch access det adj armrest

E0973 UE W/Ch access det adj armrest

E0973 UE KE W/Ch access det adj armrest

E0974 NU W/Ch access anti-rollback

E0974 RR W/Ch access anti-rollback

E0974 UE W/Ch access anti-rollback

E0978 NU W/C acc,saf belt pelv strap

E0978 NU KE W/C acc,saf belt pelv strap

E0978 RR W/C acc,saf belt pelv strap

E0978 RR KE W/C acc,saf belt pelv strap

E0978 UE W/C acc,saf belt pelv strap

E0978 UE KE W/C acc,saf belt pelv strap

17


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E0980 NU Wheelchair safety vest

E0980 RR Wheelchair safety vest

E0980 UE Wheelchair safety vest

E0981 NU Seat upholstery, replacement

E0981 NU KE Seat upholstery, replacement

E0981 RR Seat upholstery, replacement

E0981 RR KE Seat upholstery, replacement

E0981 UE Seat upholstery, replacement

E0981 UE KE Seat upholstery, replacement

E0982 NU Back upholstery, replacement

E0982 NU KE Back upholstery, replacement

E0982 RR Back upholstery, replacement

E0982 RR KE Back upholstery, replacement

E0982 UE Back upholstery, replacement

E0982 UE KE Back upholstery, replacement

E0983 RR Add pwr joystick

E0984 NU Add pwr tiller

E0984 RR Add pwr tiller

E0984 UE Add pwr tiller

E0985 NU W/c seat lift mechanism

E0985 RR W/c seat lift mechanism

E0985 UE W/c seat lift mechanism

E0986 NU Man w/c push-rim pow assist

E0986 RR Man w/c push-rim pow assist

E0986 UE Man w/c push-rim pow assist

E0990 NU Wheelchair elevating leg res

E0990 NU KE Wheelchair elevating leg res

E0990 RR Wheelchair elevating leg res

E0990 RR KE Wheelchair elevating leg res

E0990 UE Wheelchair elevating leg res

E0990 UE KE Wheelchair elevating leg res

E0992 NU Wheelchair solid seat insert

E0992 RR Wheelchair solid seat insert

E0992 UE Wheelchair solid seat insert

E0994 NU Wheelchair arm rest

E0994 RR Wheelchair arm rest

E0994 UE Wheelchair arm rest

E0995 NU Wheelchair calf rest

E0995 NU KE Wheelchair calf rest

E0995 RR Wheelchair calf rest

E0995 RR KE Wheelchair calf rest

E0995 UE Wheelchair calf rest

E0995 UE KE Wheelchair calf rest

E1002 NU Pwr seat tilt

E1002 NU KE Pwr seat tilt

E1002 RR Pwr seat tilt

E1002 RR KE Pwr seat tilt

E1002 UE Pwr seat tilt

E1002 UE KE Pwr seat tilt

E1003 NU Pwr seat recline

E1003 NU KE Pwr seat recline

E1003 RR Pwr seat recline

E1003 RR KE Pwr seat recline

E1003 UE Pwr seat recline

E1003 UE KE Pwr seat recline

E1004 NU Pwr seat recline mech

18


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E1004 NU KE Pwr seat recline mech

E1004 RR Pwr seat recline mech

E1004 RR KE Pwr seat recline mech

E1004 UE Pwr seat recline mech

E1004 UE KE Pwr seat recline mech

E1005 NU Pwr seat recline pwr

E1005 NU KE Pwr seat recline pwr

E1005 RR Pwr seat recline pwr

E1005 RR KE Pwr seat recline pwr

E1005 UE Pwr seat recline pwr

E1005 UE KE Pwr seat recline pwr

E1006 NU Pwr seat combo w/o shear

E1006 NU KE Pwr seat combo w/o shear

E1006 RR Pwr seat combo w/o shear

E1006 RR KE Pwr seat combo w/o shear

E1006 UE Pwr seat combo w/o shear

E1006 UE KE Pwr seat combo w/o shear

E1007 NU Pwr seat combo w/shear

E1007 NU KE Pwr seat combo w/shear

E1007 RR Pwr seat combo w/shear

E1007 RR KE Pwr seat combo w/shear

E1007 UE Pwr seat combo w/shear

E1007 UE KE Pwr seat combo w/shear

E1008 NU Pwr seat combo pwr shear

E1008 NU KE Pwr seat combo pwr shear

E1008 RR Pwr seat combo pwr shear

E1008 RR KE Pwr seat combo pwr shear

E1008 UE Pwr seat combo pwr shear

E1008 UE KE Pwr seat combo pwr shear

E1009 NU Add mech leg elevation

E1009 RR Add mech leg elevation

E1009 UE Add mech leg elevation

E1010 NU Add pwr leg elevation

E1010 NU KE Add pwr leg elevation

E1010 RR Add pwr leg elevation

E1010 RR KE Add pwr leg elevation

E1010 UE Add pwr leg elevation

E1010 UE KE Add pwr leg elevation

E1011 NU Ped wc modify width adjustm

E1011 RR Ped wc modify width adjustm

E1011 UE Ped wc modify width adjustm

E1014 NU Reclining back add ped w/c

E1014 RR Reclining back add ped w/c

E1014 UE Reclining back add ped w/c

E1015 NU Shock absorber for man w/c

E1015 RR Shock absorber for man w/c

E1015 UE Shock absorber for man w/c

E1016 NU Shock absorber for power w/c

E1016 NU KE Shock absorber for power w/c

E1016 RR Shock absorber for power w/c

E1016 RR KE Shock absorber for power w/c

E1016 UE Shock absorber for power w/c

E1016 UE KE Shock absorber for power w/c

E1017 NU HD shck absrbr for hd man wc

E1017 RR HD shck absrbr for hd man wc

E1017 UE HD shck absrbr for hd man wc

19


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E1018 NU HD shck absrber for hd powwc

E1018 RR HD shck absrber for hd powwc

E1018 UE HD shck absrber for hd powwc

E1020 NU Residual limb support system

E1020 NU KE Residual limb support system

E1020 RR Residual limb support system

E1020 RR KE Residual limb support system

E1020 UE Residual limb support system

E1020 UE KE Residual limb support system

E1028 NU W/c manual swingaway

E1028 NU KE W/c manual swingaway

E1028 RR W/c manual swingaway

E1028 RR KE W/c manual swingaway

E1028 UE W/c manual swingaway

E1028 UE KE W/c manual swingaway

E1029 NU W/c vent tray fixed

E1029 NU KE W/c vent tray fixed

E1029 RR W/c vent tray fixed

E1029 RR KE W/c vent tray fixed

E1029 UE W/c vent tray fixed

E1029 UE KE W/c vent tray fixed

E1030 NU W/c vent tray gimbaled

E1030 NU KE W/c vent tray gimbaled

E1030 RR W/c vent tray gimbaled

E1030 RR KE W/c vent tray gimbaled

E1030 UE W/c vent tray gimbaled

E1030 UE KE W/c vent tray gimbaled

E1031 RR Rollabout chair with casters

E1035 RR Patient transfer system <300

E1036 RR Patient transfer system >300

E1037 RR Transport chair, ped size

E1038 RR Transport chair pt wt<=300lb

E1039 RR Transport chair pt wt >300lb

E1050 RR Whelchr fxd full length arms

E1060 RR Wheelchair detachable arms

E1070 RR Wheelchair detachable foot r

E1083 RR Hemi-wheelchair fixed arms

E1084 RR Hemi-wheelchair detachable a

E1087 RR Wheelchair lightwt fixed arm

E1088 RR Wheelchair lightweight det a

E1092 RR Wheelchair wide w/ leg rests

E1093 RR Wheelchair wide w/ foot rest

E1100 RR Whchr s-recl fxd arm leg res

E1110 RR Wheelchair semi-recl detach

E1150 RR Wheelchair standard w/ leg r X X

E1160 RR Wheelchair fixed arms X X

E1161 NU Manual adult wc w tiltinspac X X

E1161 RR Manual adult wc w tiltinspac X X

E1161 UE Manual adult wc w tiltinspac X X

E1170 RR Whlchr ampu fxd arm leg rest X X

E1171 RR Wheelchair amputee w/o leg r X X

E1172 RR Wheelchair amputee detach ar X X

E1180 RR Wheelchair amputee w/ foot r X X

E1190 RR Wheelchair amputee w/ leg re X X

E1195 RR Wheelchair amputee heavy dut X X

E1200 RR Wheelchair amputee fixed arm X X

20


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E1220 Wheelchair, specially sized X X

E1221 RR Wheelchair spec size w foot X X

E1222 RR Wheelchair spec size w/ leg X X

E1223 RR Wheelchair spec size w foot X X

E1224 RR Wheelchair spec size w/ leg X X

E1225 RR Manual semi-reclining back X X

E1226 NU Manual fully reclining back X X

E1226 RR Manual fully reclining back X X

E1226 UE Manual fully reclining back X X

E1227 NU Wheelchair spec sz spec ht a X X

E1227 RR Wheelchair spec sz spec ht a X X

E1227 UE Wheelchair spec sz spec ht a X X

E1228 RR Wheelchair spec sz spec ht b X X

E1230 NU Power operated vehicle X X

E1230 RR Power operated vehicle X X

E1230 UE Power operated vehicle X X

E1231 NU Rigid ped w/c tilt-in-space X X

E1231 RR Rigid ped w/c tilt-in-space X X

E1231 UE Rigid ped w/c tilt-in-space X X

E1232 NU Folding ped wc tilt-in-space X X

E1232 RR Folding ped wc tilt-in-space X X

E1232 UE Folding ped wc tilt-in-space X X

E1233 NU Rig ped wc tltnspc w/o seat X X

E1233 RR Rig ped wc tltnspc w/o seat X X

E1233 UE Rig ped wc tltnspc w/o seat X X

E1234 NU Fld ped wc tltnspc w/o seat X X

E1234 RR Fld ped wc tltnspc w/o seat X X

E1234 UE Fld ped wc tltnspc w/o seat X X

E1235 NU Rigid ped wc adjustable X X

E1235 RR Rigid ped wc adjustable X X

E1235 UE Rigid ped wc adjustable X X

E1236 NU Folding ped wc adjustable X X

E1236 RR Folding ped wc adjustable X X

E1236 UE Folding ped wc adjustable X X

E1237 NU Rgd ped wc adjstabl w/o seat X X

E1237 RR Rgd ped wc adjstabl w/o seat X X

E1237 UE Rgd ped wc adjstabl w/o seat X X

E1238 NU Fld ped wc adjstabl w/o seat X X

E1238 RR Fld ped wc adjstabl w/o seat X X

E1238 UE Fld ped wc adjstabl w/o seat X X

E1240 RR Whchr litwt det arm leg rest X X

E1270 RR Wheelchair lightweight leg r X X

E1280 RR Whchr h-duty det arm leg res X X

E1295 RR Wheelchair heavy duty fixed X X

E1296 NU Wheelchair special seat heig X X

E1296 RR Wheelchair special seat heig X X

E1296 UE Wheelchair special seat heig X X

E1297 NU Wheelchair special seat dept X X

E1297 RR Wheelchair special seat dept X X

E1297 UE Wheelchair special seat dept X X

E1298 NU Wheelchair spec seat depth/w X X

E1298 RR Wheelchair spec seat depth/w X X

E1298 UE Wheelchair spec seat depth/w X X

E1310 NU Whirlpool non-portable X

E1310 RR Whirlpool non-portable X

E1310 UE Whirlpool non-portable X

21


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E1353 Oxygen supplies regulator X

E1355 Oxygen supplies stand/rack X

E1372 NU Oxy suppl heater for nebuliz X

E1372 RR Oxy suppl heater for nebuliz X

E1372 UE Oxy suppl heater for nebuliz X

E1390 RR Oxygen concentrator X

E1391 RR Oxygen concentrator, dual X

E1392 RR Portable oxygen concentrator X

E1405 RR O2/water vapor enrich w/heat X

E1406 RR O2/water vapor enrich w/o he

E1700 NU Jaw motion rehab system

E1700 RR Jaw motion rehab system

E1700 UE Jaw motion rehab system

E1701 Repl cushions for jaw motion

E1702 Repl measr scales jaw motion

E1800 RR Adjust elbow ext/flex device

E1801 RR SPS elbow device

E1802 RR Adjst forearm pro/sup device

E1805 RR Adjust wrist ext/flex device

E1806 RR SPS wrist device

E1810 RR Adjust knee ext/flex device

E1811 RR SPS knee device

E1812 RR Knee ext/flex w act res ctrl

E1815 RR Adjust ankle ext/flex device

E1816 RR SPS ankle device

E1818 RR SPS forearm device

E1820 NU Soft interface material

E1820 RR Soft interface material

E1820 UE Soft interface material

E1821 NU Replacement interface SPSD

E1821 RR Replacement interface SPSD

E1821 UE Replacement interface SPSD

E1825 RR Adjust finger ext/flex devc

E1830 RR Adjust toe ext/flex device

E1831 RR Static str toe dev ext/flex

E1840 RR Adj shoulder ext/flex device

E1841 RR Static str shldr dev rom adj

E2000 RR Gastric suction pump hme mdl

E2100 NU Bld glucose monitor w voice

E2100 RR Bld glucose monitor w voice

E2100 UE Bld glucose monitor w voice

E2101 NU Bld glucose monitor w lance

E2101 RR Bld glucose monitor w lance

E2101 UE Bld glucose monitor w lance

E2120 RR Pulse gen sys tx endolymp fl

E2201 NU Man w/ch acc seat w>=20"<24"

E2201 RR Man w/ch acc seat w>=20"<24"

E2201 UE Man w/ch acc seat w>=20"<24"

E2202 NU Seat width 24-27 in

E2202 RR Seat width 24-27 in

E2202 UE Seat width 24-27 in

E2203 NU Frame depth less than 22 in

E2203 RR Frame depth less than 22 in

E2203 UE Frame depth less than 22 in

E2204 NU Frame depth 22 to 25 in

E2204 RR Frame depth 22 to 25 in

22


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2204 UE Frame depth 22 to 25 in

E2205 NU Manual wc accessory, handrim

E2205 RR Manual wc accessory, handrim

E2205 UE Manual wc accessory, handrim

E2206 NU Complete wheel lock assembly

E2206 RR Complete wheel lock assembly

E2206 UE Complete wheel lock assembly

E2207 NU Crutch and cane holder

E2207 RR Crutch and cane holder

E2207 UE Crutch and cane holder

E2208 NU Cylinder tank carrier

E2208 NU KE Cylinder tank carrier

E2208 RR Cylinder tank carrier

E2208 RR KE Cylinder tank carrier

E2208 UE Cylinder tank carrier

E2208 UE KE Cylinder tank carrier

E2209 NU Arm trough each

E2209 NU KE Arm trough each

E2209 RR Arm trough each

E2209 RR KE Arm trough each

E2209 UE Arm trough each

E2209 UE KE Arm trough each

E2210 NU Wheelchair bearings

E2210 NU KE Wheelchair bearings

E2210 RR Wheelchair bearings

E2210 RR KE Wheelchair bearings

E2210 UE Wheelchair bearings

E2210 UE KE Wheelchair bearings

E2211 NU Pneumatic propulsion tire

E2211 RR Pneumatic propulsion tire

E2211 UE Pneumatic propulsion tire

E2212 NU Pneumatic prop tire tube

E2212 RR Pneumatic prop tire tube

E2212 UE Pneumatic prop tire tube

E2213 NU Pneumatic prop tire insert

E2213 RR Pneumatic prop tire insert

E2213 UE Pneumatic prop tire insert

E2214 NU Pneumatic caster tire each

E2214 RR Pneumatic caster tire each

E2214 UE Pneumatic caster tire each

E2215 NU Pneumatic caster tire tube

E2215 RR Pneumatic caster tire tube

E2215 UE Pneumatic caster tire tube

E2216 NU Foam filled propulsion tire

E2216 RR Foam filled propulsion tire

E2216 UE Foam filled propulsion tire

E2217 NU Foam filled caster tire each

E2217 RR Foam filled caster tire each

E2217 UE Foam filled caster tire each

E2218 NU Foam propulsion tire each

E2218 RR Foam propulsion tire each

E2218 UE Foam propulsion tire each

E2219 NU Foam caster tire any size ea

E2219 RR Foam caster tire any size ea

E2219 UE Foam caster tire any size ea

E2220 NU Solid propulsion tire each

23


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2220 RR Solid propulsion tire each

E2220 UE Solid propulsion tire each

E2221 NU Solid caster tire each

E2221 RR Solid caster tire each

E2221 UE Solid caster tire each

E2222 NU Solid caster integrated whl

E2222 RR Solid caster integrated whl

E2222 UE Solid caster integrated whl

E2224 NU Propulsion whl excludes tire

E2224 RR Propulsion whl excludes tire

E2224 UE Propulsion whl excludes tire

E2225 NU Caster wheel excludes tire

E2225 RR Caster wheel excludes tire

E2225 UE Caster wheel excludes tire

E2226 NU Caster fork replacement only

E2226 RR Caster fork replacement only

E2226 UE Caster fork replacement only

E2227 NU Gear reduction drive wheel

E2227 RR Gear reduction drive wheel

E2227 UE Gear reduction drive wheel

E2228 NU Mwc acc, wheelchair brake

E2228 RR Mwc acc, wheelchair brake

E2228 UE Mwc acc, wheelchair brake

E2231 NU Solid seat support base

E2231 RR Solid seat support base

E2231 UE Solid seat support base

E2310 NU Electro connect btw control

E2310 NU KE Electro connect btw control

E2310 RR Electro connect btw control

E2310 RR KE Electro connect btw control

E2310 UE Electro connect btw control

E2310 UE KE Electro connect btw control

E2311 NU Electro connect btw 2 sys

E2311 NU KE Electro connect btw 2 sys

E2311 RR Electro connect btw 2 sys

E2311 RR KE Electro connect btw 2 sys

E2311 UE Electro connect btw 2 sys

E2311 UE KE Electro connect btw 2 sys

E2312 NU Mini-prop remote joystick

E2312 NU KC Mini-prop remote joystick

E2312 RR Mini-prop remote joystick

E2312 RR KC Mini-prop remote joystick

E2312 UE Mini-prop remote joystick

E2312 UE KC Mini-prop remote joystick

E2313 NU PWC harness, expand control

E2313 RR PWC harness, expand control

E2313 UE PWC harness, expand control

E2321 NU Hand interface joystick

E2321 NU KC Hand interface joystick

E2321 NU KE Hand interface joystick

E2321 RR Hand interface joystick

E2321 RR KC Hand interface joystick

E2321 RR KE Hand interface joystick

E2321 UE Hand interface joystick

E2321 UE KC Hand interface joystick

E2321 UE KE Hand interface joystick

24


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2322 NU Mult mech switches

E2322 NU KC Mult mech switches

E2322 NU KE Mult mech switches

E2322 RR Mult mech switches

E2322 RR KC Mult mech switches

E2322 RR KE Mult mech switches

E2322 UE Mult mech switches

E2322 UE KC Mult mech switches

E2322 UE KE Mult mech switches

E2323 NU Special joystick handle

E2323 NU KE Special joystick handle

E2323 RR Special joystick handle

E2323 RR KE Special joystick handle

E2323 UE Special joystick handle

E2323 UE KE Special joystick handle

E2324 NU Chin cup interface

E2324 NU KE Chin cup interface

E2324 RR Chin cup interface

E2324 RR KE Chin cup interface

E2324 UE Chin cup interface

E2324 UE KE Chin cup interface

E2325 NU Sip and puff interface

E2325 NU KE Sip and puff interface

E2325 RR Sip and puff interface

E2325 RR KE Sip and puff interface

E2325 UE Sip and puff interface

E2325 UE KE Sip and puff interface

E2326 NU Breath tube kit

E2326 NU KE Breath tube kit

E2326 RR Breath tube kit

E2326 RR KE Breath tube kit

E2326 UE Breath tube kit

E2326 UE KE Breath tube kit

E2327 NU Head control interface mech

E2327 NU KC Head control interface mech

E2327 NU KE Head control interface mech

E2327 RR Head control interface mech

E2327 RR KC Head control interface mech

E2327 RR KE Head control interface mech

E2327 UE Head control interface mech

E2327 UE KC Head control interface mech

E2327 UE KE Head control interface mech

E2328 NU Head/extremity control inter

E2328 NU KE Head/extremity control inter

E2328 RR Head/extremity control inter

E2328 RR KE Head/extremity control inter

E2328 UE Head/extremity control inter

E2328 UE KE Head/extremity control inter

E2329 NU Head control nonproportional

E2329 NU KE Head control nonproportional

E2329 RR Head control nonproportional

E2329 RR KE Head control nonproportional

E2329 UE Head control nonproportional

E2329 UE KE Head control nonproportional

E2330 NU Head control proximity switc

E2330 NU KE Head control proximity switc

25


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2330 RR Head control proximity switc

E2330 RR KE Head control proximity switc

E2330 UE Head control proximity switc

E2330 UE KE Head control proximity switc

E2340 NU W/c wdth 20-23 in seat frame

E2340 RR W/c wdth 20-23 in seat frame

E2340 UE W/c wdth 20-23 in seat frame

E2341 NU W/c wdth 24-27 in seat frame

E2341 RR W/c wdth 24-27 in seat frame

E2341 UE W/c wdth 24-27 in seat frame

E2342 NU W/c dpth 20-21 in seat frame

E2342 RR W/c dpth 20-21 in seat frame

E2342 UE W/c dpth 20-21 in seat frame

E2343 NU W/c dpth 22-25 in seat frame

E2343 RR W/c dpth 22-25 in seat frame

E2343 UE W/c dpth 22-25 in seat frame

E2351 NU Electronic SGD interface

E2351 NU KE Electronic SGD interface

E2351 RR Electronic SGD interface

E2351 RR KE Electronic SGD interface

E2351 UE Electronic SGD interface

E2351 UE KE Electronic SGD interface

E2360 NU 22nf nonsealed leadacid

E2360 RR 22nf nonsealed leadacid

E2360 UE 22nf nonsealed leadacid

E2361 NU 22nf sealed leadacid battery

E2361 NU KE 22nf sealed leadacid battery

E2361 RR 22nf sealed leadacid battery

E2361 RR KE 22nf sealed leadacid battery

E2361 UE 22nf sealed leadacid battery

E2361 UE KE 22nf sealed leadacid battery

E2362 NU Gr24 nonsealed leadacid

E2362 RR Gr24 nonsealed leadacid

E2362 UE Gr24 nonsealed leadacid

E2363 NU Gr24 sealed leadacid battery

E2363 NU KE Gr24 sealed leadacid battery

E2363 RR Gr24 sealed leadacid battery

E2363 RR KE Gr24 sealed leadacid battery

E2363 UE Gr24 sealed leadacid battery

E2363 UE KE Gr24 sealed leadacid battery

E2364 NU U1nonsealed leadacid battery

E2364 RR U1nonsealed leadacid battery

E2364 UE U1nonsealed leadacid battery

E2365 NU U1 sealed leadacid battery

E2365 NU KE U1 sealed leadacid battery

E2365 RR U1 sealed leadacid battery

E2365 RR KE U1 sealed leadacid battery

E2365 UE U1 sealed leadacid battery

E2365 UE KE U1 sealed leadacid battery

E2366 NU Battery charger, single mode

E2366 NU KE Battery charger, single mode

E2366 RR Battery charger, single mode

E2366 RR KE Battery charger, single mode

E2366 UE Battery charger, single mode

E2366 UE KE Battery charger, single mode

E2367 NU Battery charger, dual mode

26


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2367 NU KE Battery charger, dual mode

E2367 RR Battery charger, dual mode

E2367 RR KE Battery charger, dual mode

E2367 UE Battery charger, dual mode

E2367 UE KE Battery charger, dual mode

E2368 NU Power wc motor replacement

E2368 NU KE Power wc motor replacement

E2368 RR Power wc motor replacement

E2368 RR KE Power wc motor replacement

E2368 UE Power wc motor replacement

E2368 UE KE Power wc motor replacement

E2369 NU Pwr wc gear box replacement

E2369 NU KE Pwr wc gear box replacement

E2369 RR Pwr wc gear box replacement

E2369 RR KE Pwr wc gear box replacement

E2369 UE Pwr wc gear box replacement

E2369 UE KE Pwr wc gear box replacement

E2370 NU Pwr wc motor/gear box combo

E2370 NU KE Pwr wc motor/gear box combo

E2370 RR Pwr wc motor/gear box combo

E2370 RR KE Pwr wc motor/gear box combo

E2370 UE Pwr wc motor/gear box combo

E2370 UE KE Pwr wc motor/gear box combo

E2371 NU Gr27 sealed leadacid battery

E2371 NU KE Gr27 sealed leadacid battery

E2371 RR Gr27 sealed leadacid battery

E2371 RR KE Gr27 sealed leadacid battery

E2371 UE Gr27 sealed leadacid battery

E2371 UE KE Gr27 sealed leadacid battery

E2372 NU Gr27 non-sealed leadacid

E2372 RR Gr27 non-sealed leadacid

E2372 UE Gr27 non-sealed leadacid

E2373 NU Hand/chin ctrl spec joystick

E2373 NU KC Hand/chin ctrl spec joystick

E2373 NU KE Hand/chin ctrl spec joystick

E2373 RR Hand/chin ctrl spec joystick

E2373 RR KC Hand/chin ctrl spec joystick

E2373 RR KE Hand/chin ctrl spec joystick

E2373 UE Hand/chin ctrl spec joystick

E2373 UE KC Hand/chin ctrl spec joystick

E2373 UE KE Hand/chin ctrl spec joystick

E2374 NU Hand/chin ctrl std joystick

E2374 NU KE Hand/chin ctrl std joystick

E2374 RR Hand/chin ctrl std joystick

E2374 RR KE Hand/chin ctrl std joystick

E2374 UE Hand/chin ctrl std joystick

E2374 UE KE Hand/chin ctrl std joystick

E2375 NU Non-expandable controller

E2375 NU KE Non-expandable controller

E2375 RR Non-expandable controller

E2375 RR KE Non-expandable controller

E2375 UE Non-expandable controller

E2375 UE KE Non-expandable controller

E2376 NU Expandable controller, repl

E2376 NU KE Expandable controller, repl

E2376 RR Expandable controller, repl

27


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2376 RR KE Expandable controller, repl

E2376 UE Expandable controller, repl

E2376 UE KE Expandable controller, repl

E2377 NU Expandable controller, initl

E2377 NU KE Expandable controller, initl

E2377 RR Expandable controller, initl

E2377 RR KE Expandable controller, initl

E2377 UE Expandable controller, initl

E2377 UE KE Expandable controller, initl

E2381 NU Pneum drive wheel tire

E2381 NU KE Pneum drive wheel tire

E2381 RR Pneum drive wheel tire

E2381 RR KE Pneum drive wheel tire

E2381 UE Pneum drive wheel tire

E2381 UE KE Pneum drive wheel tire

E2382 NU Tube, pneum wheel drive tire

E2382 NU KE Tube, pneum wheel drive tire

E2382 RR Tube, pneum wheel drive tire

E2382 RR KE Tube, pneum wheel drive tire

E2382 UE Tube, pneum wheel drive tire

E2382 UE KE Tube, pneum wheel drive tire

E2383 NU Insert, pneum wheel drive

E2383 NU KE Insert, pneum wheel drive

E2383 RR Insert, pneum wheel drive

E2383 RR KE Insert, pneum wheel drive

E2383 UE Insert, pneum wheel drive

E2383 UE KE Insert, pneum wheel drive

E2384 NU Pneumatic caster tire

E2384 NU KE Pneumatic caster tire

E2384 RR Pneumatic caster tire

E2384 RR KE Pneumatic caster tire

E2384 UE Pneumatic caster tire

E2384 UE KE Pneumatic caster tire

E2385 NU Tube, pneumatic caster tire

E2385 NU KE Tube, pneumatic caster tire

E2385 RR Tube, pneumatic caster tire

E2385 RR KE Tube, pneumatic caster tire

E2385 UE Tube, pneumatic caster tire

E2385 UE KE Tube, pneumatic caster tire

E2386 NU Foam filled drive wheel tire

E2386 NU KE Foam filled drive wheel tire

E2386 RR Foam filled drive wheel tire

E2386 RR KE Foam filled drive wheel tire

E2386 UE Foam filled drive wheel tire

E2386 UE KE Foam filled drive wheel tire

E2387 NU Foam filled caster tire

E2387 NU KE Foam filled caster tire

E2387 RR Foam filled caster tire

E2387 RR KE Foam filled caster tire

E2387 UE Foam filled caster tire

E2387 UE KE Foam filled caster tire

E2388 NU Foam drive wheel tire

E2388 NU KE Foam drive wheel tire

E2388 RR Foam drive wheel tire

E2388 RR KE Foam drive wheel tire

E2388 UE Foam drive wheel tire

28


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2388 UE KE Foam drive wheel tire

E2389 NU Foam caster tire

E2389 NU KE Foam caster tire

E2389 RR Foam caster tire

E2389 RR KE Foam caster tire

E2389 UE Foam caster tire

E2389 UE KE Foam caster tire

E2390 NU Solid drive wheel tire

E2390 NU KE Solid drive wheel tire

E2390 RR Solid drive wheel tire

E2390 RR KE Solid drive wheel tire

E2390 UE Solid drive wheel tire

E2390 UE KE Solid drive wheel tire

E2391 NU Solid caster tire

E2391 NU KE Solid caster tire

E2391 RR Solid caster tire

E2391 RR KE Solid caster tire

E2391 UE Solid caster tire

E2391 UE KE Solid caster tire

E2392 NU Solid caster tire, integrate

E2392 NU KE Solid caster tire, integrate

E2392 RR Solid caster tire, integrate

E2392 RR KE Solid caster tire, integrate

E2392 UE Solid caster tire, integrate

E2392 UE KE Solid caster tire, integrate

E2394 NU Drive wheel excludes tire

E2394 NU KE Drive wheel excludes tire

E2394 RR Drive wheel excludes tire

E2394 RR KE Drive wheel excludes tire

E2394 UE Drive wheel excludes tire

E2394 UE KE Drive wheel excludes tire

E2395 NU Caster wheel excludes tire

E2395 NU KE Caster wheel excludes tire

E2395 RR Caster wheel excludes tire

E2395 RR KE Caster wheel excludes tire

E2395 UE Caster wheel excludes tire

E2395 UE KE Caster wheel excludes tire

E2396 NU Caster fork

E2396 NU KE Caster fork

E2396 RR Caster fork

E2396 RR KE Caster fork

E2396 UE Caster fork

E2396 UE KE Caster fork

E2397 NU Pwc acc, lith-based battery

E2397 RR Pwc acc, lith-based battery

E2397 UE Pwc acc, lith-based battery

E2402 RR Neg press wound therapy pump X X

E2500 NU SGD digitized pre-rec <=8min

E2500 RR SGD digitized pre-rec <=8min

E2500 UE SGD digitized pre-rec <=8min

E2502 NU SGD prerec msg >8min <=20min

E2502 RR SGD prerec msg >8min <=20min

E2502 UE SGD prerec msg >8min <=20min

E2504 NU SGD prerec msg>20min <=40min

E2504 RR SGD prerec msg>20min <=40min

E2504 UE SGD prerec msg>20min <=40min

29


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2506 NU SGD prerec msg > 40 min

E2506 RR SGD prerec msg > 40 min

E2506 UE SGD prerec msg > 40 min

E2508 NU SGD spelling phys contact

E2508 RR SGD spelling phys contact

E2508 UE SGD spelling phys contact

E2510 NU SGD w multi methods msg/accs

E2510 RR SGD w multi methods msg/accs

E2510 UE SGD w multi methods msg/accs

E2511 NU SGD sftwre prgrm for PC/PDA

E2511 RR SGD sftwre prgrm for PC/PDA

E2511 UE SGD sftwre prgrm for PC/PDA

E2512 NU SGD accessory, mounting sys

E2512 RR SGD accessory, mounting sys

E2512 UE SGD accessory, mounting sys

E2601 NU Gen w/c cushion wdth < 22 in

E2601 NU KE Gen w/c cushion wdth < 22 in

E2601 RR Gen w/c cushion wdth < 22 in

E2601 RR KE Gen w/c cushion wdth < 22 in

E2601 UE Gen w/c cushion wdth < 22 in

E2601 UE KE Gen w/c cushion wdth < 22 in

E2602 NU Gen w/c cushion wdth >=22 in

E2602 NU KE Gen w/c cushion wdth >=22 in

E2602 RR Gen w/c cushion wdth >=22 in

E2602 RR KE Gen w/c cushion wdth >=22 in

E2602 UE Gen w/c cushion wdth >=22 in

E2602 UE KE Gen w/c cushion wdth >=22 in

E2603 NU Skin protect wc cus wd <22in

E2603 NU KE Skin protect wc cus wd <22in

E2603 RR Skin protect wc cus wd <22in

E2603 RR KE Skin protect wc cus wd <22in

E2603 UE Skin protect wc cus wd <22in

E2603 UE KE Skin protect wc cus wd <22in

E2604 NU Skin protect wc cus wd>=22in

E2604 NU KE Skin protect wc cus wd>=22in

E2604 RR Skin protect wc cus wd>=22in

E2604 RR KE Skin protect wc cus wd>=22in

E2604 UE Skin protect wc cus wd>=22in

E2604 UE KE Skin protect wc cus wd>=22in

E2605 NU Position wc cush wdth <22 in

E2605 NU KE Position wc cush wdth <22 in

E2605 RR Position wc cush wdth <22 in

E2605 RR KE Position wc cush wdth <22 in

E2605 UE Position wc cush wdth <22 in

E2605 UE KE Position wc cush wdth <22 in

E2606 NU Position wc cush wdth>=22 in

E2606 NU KE Position wc cush wdth>=22 in

E2606 RR Position wc cush wdth>=22 in

E2606 RR KE Position wc cush wdth>=22 in

E2606 UE Position wc cush wdth>=22 in

E2606 UE KE Position wc cush wdth>=22 in

E2607 NU Skin pro/pos wc cus wd <22in

E2607 NU KE Skin pro/pos wc cus wd <22in

E2607 RR Skin pro/pos wc cus wd <22in

E2607 RR KE Skin pro/pos wc cus wd <22in

E2607 UE Skin pro/pos wc cus wd <22in

30


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2607 UE KE Skin pro/pos wc cus wd <22in

E2608 NU Skin pro/pos wc cus wd>=22in

E2608 NU KE Skin pro/pos wc cus wd>=22in

E2608 RR Skin pro/pos wc cus wd>=22in

E2608 RR KE Skin pro/pos wc cus wd>=22in

E2608 UE Skin pro/pos wc cus wd>=22in

E2608 UE KE Skin pro/pos wc cus wd>=22in

E2611 NU Gen use back cush wdth <22in

E2611 NU KE Gen use back cush wdth <22in

E2611 RR Gen use back cush wdth <22in

E2611 RR KE Gen use back cush wdth <22in

E2611 UE Gen use back cush wdth <22in

E2611 UE KE Gen use back cush wdth <22in

E2612 NU Gen use back cush wdth>=22in

E2612 NU KE Gen use back cush wdth>=22in

E2612 RR Gen use back cush wdth>=22in

E2612 RR KE Gen use back cush wdth>=22in

E2612 UE Gen use back cush wdth>=22in

E2612 UE KE Gen use back cush wdth>=22in

E2613 NU Position back cush wd <22in

E2613 NU KE Position back cush wd <22in

E2613 RR Position back cush wd <22in

E2613 RR KE Position back cush wd <22in

E2613 UE Position back cush wd <22in

E2613 UE KE Position back cush wd <22in

E2614 NU Position back cush wd>=22in

E2614 NU KE Position back cush wd>=22in

E2614 RR Position back cush wd>=22in

E2614 RR KE Position back cush wd>=22in

E2614 UE Position back cush wd>=22in

E2614 UE KE Position back cush wd>=22in

E2615 NU Pos back post/lat wdth <22in

E2615 NU KE Pos back post/lat wdth <22in

E2615 RR Pos back post/lat wdth <22in

E2615 RR KE Pos back post/lat wdth <22in

E2615 UE Pos back post/lat wdth <22in

E2615 UE KE Pos back post/lat wdth <22in

E2616 NU Pos back post/lat wdth>=22in

E2616 NU KE Pos back post/lat wdth>=22in

E2616 RR Pos back post/lat wdth>=22in

E2616 RR KE Pos back post/lat wdth>=22in

E2616 UE Pos back post/lat wdth>=22in

E2616 UE KE Pos back post/lat wdth>=22in

E2619 NU Replace cover w/c seat cush

E2619 NU KE Replace cover w/c seat cush

E2619 RR Replace cover w/c seat cush

E2619 RR KE Replace cover w/c seat cush

E2619 UE Replace cover w/c seat cush

E2619 UE KE Replace cover w/c seat cush

E2620 NU WC planar back cush wd <22in

E2620 NU KE WC planar back cush wd <22in

E2620 RR WC planar back cush wd <22in

E2620 RR KE WC planar back cush wd <22in

E2620 UE WC planar back cush wd <22in

E2620 UE KE WC planar back cush wd <22in

E2621 NU WC planar back cush wd>=22in

31


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

E2621 NU KE WC planar back cush wd>=22in

E2621 RR WC planar back cush wd>=22in

E2621 RR KE WC planar back cush wd>=22in

E2621 UE WC planar back cush wd>=22in

E2621 UE KE WC planar back cush wd>=22in

E2622 NU Adj skin pro w/c cus wd<22in

E2622 NU KE Adj skin pro w/c cus wd<22in

E2622 RR Adj skin pro w/c cus wd<22in

E2622 RR KE Adj skin pro w/c cus wd<22in

E2622 UE Adj skin pro w/c cus wd<22in

E2622 UE KE Adj skin pro w/c cus wd<22in

E2623 NU Adj skin pro wc cus wd>=22in

E2623 NU KE Adj skin pro wc cus wd>=22in

E2623 RR Adj skin pro wc cus wd>=22in

E2623 RR KE Adj skin pro wc cus wd>=22in

E2623 UE Adj skin pro wc cus wd>=22in

E2623 UE KE Adj skin pro wc cus wd>=22in

E2624 NU Adj skin pro/pos cus<22in

E2624 NU KE Adj skin pro/pos cus<22in

E2624 RR Adj skin pro/pos cus<22in

E2624 RR KE Adj skin pro/pos cus<22in

E2624 UE Adj skin pro/pos cus<22in

E2624 UE KE Adj skin pro/pos cus<22in

E2625 NU Adj skin pro/pos wc cus>=22

E2625 NU KE Adj skin pro/pos wc cus>=22

E2625 RR Adj skin pro/pos wc cus>=22

E2625 RR KE Adj skin pro/pos wc cus>=22

E2625 UE Adj skin pro/pos wc cus>=22

E2625 UE KE Adj skin pro/pos wc cus>=22

Wheelchairs & Accessories

K0001 RR Standard wheelchair

K0002 RR Stnd hemi (low seat) whlchr

K0003 RR Lightweight wheelchair X X

K0004 RR High strength ltwt whlchr X X

K0005 NU Ultralightweight wheelchair X X

K0005 RR Ultralightweight wheelchair X X

K0005 UE Ultralightweight wheelchair X X

K0006 RR Heavy duty wheelchair X X

K0007 RR Extra heavy duty wheelchair X X

K0010 RR Stnd wt frame power whlchr X X

K0011 RR Stnd wt pwr whlchr w control X X

K0011 RR KF Stnd wt pwr whlchr w control X X

K0012 RR Ltwt portbl power whlchr X X

K0015 NU Detach non-adjus hght armrst X X

K0015 NU KE Detach non-adjus hght armrst X X

K0015 RR Detach non-adjus hght armrst X X

K0015 RR KE Detach non-adjus hght armrst X X

K0015 UE Detach non-adjus hght armrst X X

K0015 UE KE Detach non-adjus hght armrst X X

K0017 NU Detach adjust armrest base X X

K0017 NU KE Detach adjust armrest base X X

K0017 RR Detach adjust armrest base X X

K0017 RR KE Detach adjust armrest base X X

K0017 UE Detach adjust armrest base X X

K0017 UE KE Detach adjust armrest base X X

K0018 NU Detach adjust armrst upper X X

32


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

K0018 NU KE Detach adjust armrst upper X X

K0018 RR Detach adjust armrst upper X X

K0018 RR KE Detach adjust armrst upper X X

K0018 UE Detach adjust armrst upper X X

K0018 UE KE Detach adjust armrst upper X X

K0019 NU Arm pad each X X

K0019 NU KE Arm pad each X X

K0019 RR Arm pad each X X

K0019 RR KE Arm pad each X X

K0019 UE Arm pad each X X

K0019 UE KE Arm pad each X X

K0020 NU Fixed adjust armrest pair X X

K0020 NU KE Fixed adjust armrest pair X X

K0020 RR Fixed adjust armrest pair X X

K0020 RR KE Fixed adjust armrest pair X X

K0020 UE Fixed adjust armrest pair X X

K0020 UE KE Fixed adjust armrest pair X X

K0037 NU High mount flip-up footrest X X

K0037 NU KE High mount flip-up footrest X X

K0037 RR High mount flip-up footrest X X

K0037 RR KE High mount flip-up footrest X X

K0037 UE High mount flip-up footrest X X

K0037 UE KE High mount flip-up footrest X X

K0038 NU Leg strap each X X

K0038 NU KE Leg strap each X X

K0038 RR Leg strap each X X

K0038 RR KE Leg strap each X X

K0038 UE Leg strap each X X

K0038 UE KE Leg strap each X X

K0039 NU Leg strap h style each X X

K0039 NU KE Leg strap h style each X X

K0039 RR Leg strap h style each X X

K0039 RR KE Leg strap h style each X X

K0039 UE Leg strap h style each X X

K0039 UE KE Leg strap h style each X X

K0040 NU Adjustable angle footplate X X

K0040 NU KE Adjustable angle footplate X X

K0040 RR Adjustable angle footplate X X

K0040 RR KE Adjustable angle footplate X X

K0040 UE Adjustable angle footplate X X

K0040 UE KE Adjustable angle footplate X X

K0041 NU Large size footplate each X X

K0041 NU KE Large size footplate each X X

K0041 RR Large size footplate each X X

K0041 RR KE Large size footplate each X X

K0041 UE Large size footplate each X X

K0041 UE KE Large size footplate each X X

K0042 NU Standard size footplate each X X

K0042 NU KE Standard size footplate each X X

K0042 RR Standard size footplate each X X

K0042 RR KE Standard size footplate each X X

K0042 UE Standard size footplate each X X

K0042 UE KE Standard size footplate each X X

K0043 NU Ftrst lower extension tube X X

K0043 NU KE Ftrst lower extension tube X X

K0043 RR Ftrst lower extension tube X X

33


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

K0043 RR KE Ftrst lower extension tube X X

K0043 UE Ftrst lower extension tube X X

K0043 UE KE Ftrst lower extension tube X X

K0044 NU Ftrst upper hanger bracket X X

K0044 NU KE Ftrst upper hanger bracket X X

K0044 RR Ftrst upper hanger bracket X X

K0044 RR KE Ftrst upper hanger bracket X X

K0044 UE Ftrst upper hanger bracket X X

K0044 UE KE Ftrst upper hanger bracket X X

K0045 NU Footrest complete assembly X X

K0045 NU KE Footrest complete assembly X X

K0045 RR Footrest complete assembly X X

K0045 RR KE Footrest complete assembly X X

K0045 UE Footrest complete assembly X X

K0045 UE KE Footrest complete assembly X X

K0046 NU Elevat legrst low extension X X

K0046 NU KE Elevat legrst low extension X X

K0046 RR Elevat legrst low extension X X

K0046 RR KE Elevat legrst low extension X X

K0046 UE Elevat legrst low extension X X

K0046 UE KE Elevat legrst low extension X X

K0047 NU Elevat legrst up hangr brack X X

K0047 NU KE Elevat legrst up hangr brack X X

K0047 RR Elevat legrst up hangr brack X X

K0047 RR KE Elevat legrst up hangr brack X X

K0047 UE Elevat legrst up hangr brack X X

K0047 UE KE Elevat legrst up hangr brack X X

K0050 NU Ratchet assembly X X

K0050 NU KE Ratchet assembly X X

K0050 RR Ratchet assembly X X

K0050 RR KE Ratchet assembly X X

K0050 UE Ratchet assembly X X

K0050 UE KE Ratchet assembly X X

K0051 NU Cam relese assem ftrst/lgrst X X

K0051 NU KE Cam relese assem ftrst/lgrst X X

K0051 RR Cam relese assem ftrst/lgrst X X

K0051 RR KE Cam relese assem ftrst/lgrst X X

K0051 UE Cam relese assem ftrst/lgrst X X

K0051 UE KE Cam relese assem ftrst/lgrst X X

K0052 NU Swingaway detach footrest X X

K0052 NU KE Swingaway detach footrest X X

K0052 RR Swingaway detach footrest X X

K0052 RR KE Swingaway detach footrest X X

K0052 UE Swingaway detach footrest X X

K0052 UE KE Swingaway detach footrest X X

K0053 NU Elevate footrest articulate X X

K0053 NU KE Elevate footrest articulate X X

K0053 RR Elevate footrest articulate X X

K0053 RR KE Elevate footrest articulate X X

K0053 UE Elevate footrest articulate X X

K0053 UE KE Elevate footrest articulate X X

K0056 NU Seat ht <17 or >=21 ltwt wc X X

K0056 RR Seat ht <17 or >=21 ltwt wc X X

K0056 UE Seat ht <17 or >=21 ltwt wc X X

K0065 NU Spoke protectors X X

K0065 RR Spoke protectors X X

34


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

K0065 UE Spoke protectors X X

K0069 NU Rear whl complete solid tire X X

K0069 RR Rear whl complete solid tire X X

K0069 UE Rear whl complete solid tire X X

K0070 NU Rear whl compl pneum tire X X

K0070 RR Rear whl compl pneum tire X X

K0070 UE Rear whl compl pneum tire X X

K0071 NU Front castr compl pneum tire X X

K0071 RR Front castr compl pneum tire X X

K0071 UE Front castr compl pneum tire X X

K0072 NU Frnt cstr cmpl sem-pneum tir X X

K0072 RR Frnt cstr cmpl sem-pneum tir X X

K0072 UE Frnt cstr cmpl sem-pneum tir X X

K0073 NU Caster pin lock each X X

K0073 RR Caster pin lock each X X

K0073 UE Caster pin lock each X X

K0077 NU Front caster assem complete X X

K0077 RR Front caster assem complete X X

K0077 UE Front caster assem complete X X

K0098 NU Drive belt power wheelchair X X

K0098 NU KE Drive belt power wheelchair X X

K0098 RR Drive belt power wheelchair X X

K0098 RR KE Drive belt power wheelchair X X

K0098 UE Drive belt power wheelchair X X

K0098 UE KE Drive belt power wheelchair X X

K0105 NU Iv hanger X

K0105 RR Iv hanger X

K0105 UE Iv hanger X

K0195 RR Elevating whlchair leg rests X X

K0195 RR KE Elevating whlchair leg rests X X

K0455 RR Pump uninterrupted infusion

K0552 Supply/ext inf pump syr type

K0601 NU Repl batt silver oxide 1.5 v

K0602 NU Repl batt silver oxide 3 v

K0603 NU Repl batt alkaline 1.5 v

K0604 NU Repl batt lithium 3.6 v

K0605 NU Repl batt lithium 4.5 v

K0606 RR KF AED garment w elec analysis

K0607 NU Repl batt for AED

K0607 NU KF Repl batt for AED

K0607 RR Repl batt for AED

K0607 RR KF Repl batt for AED

K0607 UE Repl batt for AED

K0607 UE KF Repl batt for AED

K0608 NU Repl garment for AED

K0608 NU KF Repl garment for AED

K0608 RR Repl garment for AED

K0608 RR KF Repl garment for AED

K0608 UE Repl garment for AED

K0608 UE KF Repl garment for AED

K0609 Repl electrode for AED

K0609 KF Repl electrode for AED

K0672 Removable soft interface LE

K0730 NU Ctrl dose inh drug deliv sys

K0730 RR Ctrl dose inh drug deliv sys

K0730 UE Ctrl dose inh drug deliv sys

35


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

K0733 NU 12-24hr sealed lead acid

K0733 NU KE 12-24hr sealed lead acid

K0733 RR 12-24hr sealed lead acid

K0733 RR KE 12-24hr sealed lead acid

K0733 UE 12-24hr sealed lead acid

K0733 UE KE 12-24hr sealed lead acid

K0738 RR Portable gas oxygen system

K0800 NU POV group 1 std up to 300lbs X X

K0800 RR POV group 1 std up to 300lbs X X

K0800 UE POV group 1 std up to 300lbs X X

K0801 NU POV group 1 hd 301-450 lbs X X

K0801 RR POV group 1 hd 301-450 lbs X X

K0801 UE POV group 1 hd 301-450 lbs X X

K0802 NU POV group 1 vhd 451-600 lbs X X

K0802 RR POV group 1 vhd 451-600 lbs X X

K0802 UE POV group 1 vhd 451-600 lbs X X

K0806 NU POV group 2 std up to 300lbs X X

K0806 RR POV group 2 std up to 300lbs X X

K0806 UE POV group 2 std up to 300lbs X X

K0807 NU POV group 2 hd 301-450 lbs X X

K0807 RR POV group 2 hd 301-450 lbs X X

K0807 UE POV group 2 hd 301-450 lbs X X

K0808 NU POV group 2 vhd 451-600 lbs X X

K0808 RR POV group 2 vhd 451-600 lbs X X

K0808 UE POV group 2 vhd 451-600 lbs X X

K0813 RR PWC gp 1 std port seat/back X X

K0814 RR PWC gp 1 std port cap chair X X

K0815 RR PWC gp 1 std seat/back X X

K0816 RR PWC gp 1 std cap chair X X

K0820 RR PWC gp 2 std port seat/back X X

K0821 RR PWC gp 2 std port cap chair X X



K0824 RR PWC gp 2 hd seat/back X X

K0825 RR PWC gp 2 hd cap chair X X

K0826 RR PWC gp 2 vhd seat/back X X

K0827 RR PWC gp vhd cap chair X X

K0828 RR PWC gp 2 xtra hd seat/back X X

K0829 RR PWC gp 2 xtra hd cap chair X X

K0835 RR PWC gp2 std sing pow opt s/b X X

K0836 RR PWC gp2 std sing pow opt cap X X

K0837 RR PWC gp 2 hd sing pow opt s/b X X

K0838 RR PWC gp 2 hd sing pow opt cap X X

K0839 RR PWC gp2 vhd sing pow opt s/b X X

K0840 RR PWC gp2 xhd sing pow opt s/b X X

K0841 RR PWC gp2 std mult pow opt s/b X X

K0842 RR PWC gp2 std mult pow opt cap X X

K0843 RR PWC gp2 hd mult pow opt s/b X X



K0850 RR PWC gp 3 hd seat/back X X

K0851 RR PWC gp 3 hd cap chair X X

K0852 RR PWC gp 3 vhd seat/back X X

K0853 RR PWC gp 3 vhd cap chair X X

K0854 RR PWC gp 3 xhd seat/back X X

K0855 RR PWC gp 3 xhd cap chair X X

36


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

K0856 RR PWC gp3 std sing pow opt s/b X X

K0857 RR PWC gp3 std sing pow opt cap X X

K0858 RR PWC gp3 hd sing pow opt s/b X X

K0859 RR PWC gp3 hd sing pow opt cap X X

K0860 RR PWC gp3 vhd sing pow opt s/b X X

K0861 RR PWC gp3 std mult pow opt s/b X X

K0861 RR KF PWC gp3 std mult pow opt s/b X X

K0862 RR PWC gp3 hd mult pow opt s/b X X

K0863 RR PWC gp3 vhd mult pow opt s/b X X

K0864 RR PWC gp3 xhd mult pow opt s/b X X

Orthotics

L0112 Cranial cervical orthosis X

L0113 Cranial cervical torticollis X X

Prosthetics

L5000 Sho insert w arch toe filler X

L5010 Mold socket ank hgt w/ toe f X

L5020 Tibial tubercle hgt w/ toe f X

L5050 Ank symes mold sckt sach ft X

L5060 Symes met fr leath socket ar X

L5100 Molded socket shin sach foot X

L5105 Plast socket jts/thgh lacer X

L5150 Mold sckt ext knee shin sach X

L5160 Mold socket bent knee shin s X

L5200 Kne sing axis fric shin sach X

L5210 No knee/ankle joints w/ ft b X

L5220 No knee joint with artic ali X

L5230 Fem focal defic constant fri X

L5250 Hip canad sing axi cons fric X

L5270 Tilt table locking hip sing X

L5280 Hemipelvect canad sing axis X

L5301 BK mold socket SACH ft endo X

L5311 Knee disart, SACH ft, endo X

L5321 AK open end SACH X

L5331 Hip disart canadian SACH ft X

L5341 Hemipelvectomy canadian SACH X

L5400 Postop dress & 1 cast chg bk X

L5410 Postop dsg bk ea add cast ch X

L5420 Postop dsg & 1 cast chg ak/d X

L5430 Postop dsg ak ea add cast ch X

L5450 Postop app non-wgt bear dsg X

L5460 Postop app non-wgt bear dsg X

L5500 Init bk ptb plaster direct X

L5505 Init ak ischal plstr direct X

L5510 Prep BK ptb plaster molded X

L5520 Perp BK ptb thermopls direct X

L5530 Prep BK ptb thermopls molded X

L5535 Prep BK ptb open end socket X

L5540 Prep BK ptb laminated socket X

L5560 Prep AK ischial plast molded X

L5570 Prep AK ischial direct form X

L5580 Prep AK ischial thermo mold X

L5585 Prep AK ischial open end X

L5590 Prep AK ischial laminated X

L5595 Hip disartic sach thermopls X

L5600 Hip disart sach laminat mold X

L5610 Above knee hydracadence X

37


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

L5611 Ak 4 bar link w/fric swing X

L5613 Ak 4 bar ling w/hydraul swig X

L5614 4-bar link above knee w/swng X

L5616 Ak univ multiplex sys frict X

L5617 AK/BK self-aligning unit ea X

L5618 Test socket symes X

L5620 Test socket below knee X

L5622 Test socket knee disarticula X

L5624 Test socket above knee X

L5626 Test socket hip disarticulat X

L5628 Test socket hemipelvectomy X

L5629 Below knee acrylic socket X

L5630 Syme typ expandabl wall sckt X

L5631 Ak/knee disartic acrylic soc X

L5632 Symes type ptb brim design s X

L5634 Symes type poster opening so X

L5636 Symes type medial opening so X

L5637 Below knee total contact X

L5638 Below knee leather socket X

L5639 Below knee wood socket X

L5640 Knee disarticulat leather so X

L5642 Above knee leather socket X

L5643 Hip flex inner socket ext fr X

L5644 Above knee wood socket X

L5645 Bk flex inner socket ext fra X

L5646 Below knee cushion socket X

L5647 Below knee suction socket X

L5648 Above knee cushion socket X

L5649 Isch containmt/narrow m-l so X

L5650 Tot contact ak/knee disart s X

L5651 Ak flex inner socket ext fra X

L5652 Suction susp ak/knee disart X

L5653 Knee disart expand wall sock X

L5654 Socket insert symes X

L5655 Socket insert below knee X

L5656 Socket insert knee articulat X

L5658 Socket insert above knee X

L5661 Multi-durometer symes X

L5665 Multi-durometer below knee X

L5666 Below knee cuff suspension X

L5668 Socket insert w/o lock lower X

L5670 Bk molded supracondylar susp X

L5671 BK/AK locking mechanism X

L5672 Bk removable medial brim sus X

L5673 Socket insert w lock mech X

L5676 Bk knee joints single axis p X

L5677 Bk knee joints polycentric p X

L5678 Bk joint covers pair X

L5679 Socket insert w/o lock mech X

L5680 Bk thigh lacer non-molded X

L5681 Intl custm cong/latyp insert X

L5682 Bk thigh lacer glut/ischia m X

L5683 Initial custom socket insert X

L5684 Bk fork strap X

L5685 Below knee sus/seal sleeve X

L5686 Bk back check X

38


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

L5688 Bk waist belt webbing X

L5690 Bk waist belt padded and lin X

L5692 Ak pelvic control belt light X

L5694 Ak pelvic control belt pad/l X

L5695 Ak sleeve susp neoprene/equa X

L5696 Ak/knee disartic pelvic join X

L5697 Ak/knee disartic pelvic band X

L5698 Ak/knee disartic silesian ba X

L5699 Shoulder harness X

L5700 Replace socket below knee X

L5701 Replace socket above knee X

L5702 Replace socket hip X

L5703 Symes ankle w/o (SACH) foot X

L5704 Custom shape cover BK X

L5705 Custom shape cover AK X

L5706 Custom shape cvr knee disart X

L5707 Custom shape cvr hip disart X

L5710 Kne-shin exo sng axi mnl loc X

L5711 Knee-shin exo mnl lock ultra X

L5712 Knee-shin exo frict swg & st X

L5714 Knee-shin exo variable frict X

L5716 Knee-shin exo mech stance ph X

L5718 Knee-shin exo frct swg & sta X

L5722 Knee-shin pneum swg frct exo X

L5724 Knee-shin exo fluid swing ph X

L5726 Knee-shin ext jnts fld swg e X

L5728 Knee-shin fluid swg & stance X

L5780 Knee-shin pneum/hydra pneum X

L5781 Lower limb pros vacuum pump X

L5782 HD low limb pros vacuum pump X

L5785 Exoskeletal bk ultralt mater X

L5790 Exoskeletal ak ultra-light m X

L5795 Exoskel hip ultra-light mate X

L5810 Endoskel knee-shin mnl lock X

L5811 Endo knee-shin mnl lck ultra X

L5812 Endo knee-shin frct swg & st X

L5814 Endo knee-shin hydral swg ph X

L5816 Endo knee-shin polyc mch sta X

L5818 Endo knee-shin frct swg & st X

L5822 Endo knee-shin pneum swg frc X

L5824 Endo knee-shin fluid swing p X

L5826 Miniature knee joint X

L5828 Endo knee-shin fluid swg/sta X

L5830 Endo knee-shin pneum/swg pha X

L5840 Multi-axial knee/shin system X

L5845 Knee-shin sys stance flexion X

L5848 Knee-shin sys hydraul stance X

L5850 Endo ak/hip knee extens assi X

L5855 Mech hip extension assist X

L5856 Elec knee-shin swing/stance X

L5857 Elec knee-shin swing only X

L5858 Stance phase only X

L5910 Endo below knee alignable sy X

L5920 Endo ak/hip alignable system X

L5925 Above knee manual lock X

L5930 High activity knee frame X

39


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

L5940 Endo bk ultra-light material X

L5950 Endo ak ultra-light material X

L5960 Endo hip ultra-light materia X

L5961 Endo poly hip, pneu/hyd/rot X

L5962 Below knee flex cover system X

L5964 Above knee flex cover system X

L5966 Hip flexible cover system X

L5968 Multiaxial ankle w dorsiflex X

L5970 Foot external keel sach foot X

L5971 SACH foot, replacement X

L5972 Flexible keel foot X

L5973 Ank-foot sys dors-plant flex X

L5974 Foot single axis ankle/foot X

L5975 Combo ankle/foot prosthesis X

L5976 Energy storing foot X

L5978 Ft prosth multiaxial ankl/ft X

L5979 Multi-axial ankle/ft prosth X

L5980 Flex foot system X

L5981 Flex-walk sys low ext prosth X

L5982 Exoskeletal axial rotation u X

L5984 Endoskeletal axial rotation X

L5985 Lwr ext dynamic prosth pylon X

L5986 Multi-axial rotation unit X

L5987 Shank ft w vert load pylon X

L5988 Vertical shock reducing pylo X

L5990 User adjustable heel height X

L6000 Par hand robin-aids thum rem X

L6010 Hand robin-aids little/ring X

L6020 Part hand robin-aids no fing X

L6025 Part hand disart myoelectric X

L6050 Wrst MLd sck flx hng tri pad X

L6055 Wrst mold sock w/exp interfa X

L6100 Elb mold sock flex hinge pad X

L6110 Elbow mold sock suspension t X

L6120 Elbow mold doub splt soc ste X

L6130 Elbow stump activated lock h X

L6200 Elbow mold outsid lock hinge X

L6205 Elbow molded w/ expand inter X

L6250 Elbow inter loc elbow forarm X

L6300 Shlder disart int lock elbow X

L6310 Shoulder passive restor comp X

L6320 Shoulder passive restor cap X

L6350 Thoracic intern lock elbow X

L6360 Thoracic passive restor comp X

L6370 Thoracic passive restor cap X

L6380 Postop dsg cast chg wrst/elb X

L6382 Postop dsg cast chg elb dis/ X

L6384 Postop dsg cast chg shlder/t X

L6386 Postop ea cast chg & realign X

L6388 Postop applicat rigid dsg on X

L6400 Below elbow prosth tiss shap X

L6450 Elb disart prosth tiss shap X

L6500 Above elbow prosth tiss shap X

L6550 Shldr disar prosth tiss shap X

L6570 Scap thorac prosth tiss shap X

L6580 Wrist/elbow bowden cable mol X

40


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

L6582 Wrist/elbow bowden cbl dir f X

L6584 Elbow fair lead cable molded X

L6586 Elbow fair lead cable dir fo X

L6588 Shdr fair lead cable molded X

L6590 Shdr fair lead cable direct X

L6600 Polycentric hinge pair X

L6605 Single pivot hinge pair X

L6610 Flexible metal hinge pair X

L6611 Additional switch, ext power X

L6615 Disconnect locking wrist uni X

L6616 Disconnect insert locking wr X

L6620 Flexion/extension wrist unit X

L6621 Flex/ext wrist w/wo friction X

L6623 Spring-ass rot wrst w/ latch X

L6624 Flex/ext/rotation wrist unit X

L6625 Rotation wrst w/ cable lock X

L6628 Quick disconn hook adapter o X

L6629 Lamination collar w/ couplin X

L6630 Stainless steel any wrist X

L6632 Latex suspension sleeve each X

L6635 Lift assist for elbow X

L6637 Nudge control elbow lock X

L6638 Elec lock on manual pw elbow X

L6640 Shoulder abduction joint pai X

L6641 Excursion amplifier pulley t X

L6642 Excursion amplifier lever ty X

L6645 Shoulder flexion-abduction j X

L6646 Multipo locking shoulder jnt X

L6647 Shoulder lock actuator X

L6648 Ext pwrd shlder lock/unlock X

L6650 Shoulder universal joint X

L6655 Standard control cable extra X

L6660 Heavy duty control cable X

L6665 Teflon or equal cable lining X

L6670 Hook to hand cable adapter X

L6672 Harness chest/shlder saddle X

L6675 Harness figure of 8 sing con X

L6676 Harness figure of 8 dual con X

L6677 UE triple control harness X

L6680 Test sock wrist disart/bel e X

L6682 Test sock elbw disart/above X

L6684 Test socket shldr disart/tho X

L6686 Suction socket X

L6687 Frame typ socket bel elbow/w X

L6688 Frame typ sock above elb/dis X

L6689 Frame typ socket shoulder di X

L6690 Frame typ sock interscap-tho X

L6691 Removable insert each X

L6692 Silicone gel insert or equal X

L6693 Lockingelbow forearm cntrbal X

L6694 Elbow socket ins use w/lock X

L6695 Elbow socket ins use w/o lck X

L6696 Cus elbo skt in for con/atyp X

L6697 Cus elbo skt in not con/atyp X

L6698 Below/above elbow lock mech X

L6703 Term dev, passive hand mitt X

41


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

L6704 Term dev, sport/rec/work att X

L6706 Term dev mech hook vol open X

L6707 Term dev mech hook vol close X

L6708 Term dev mech hand vol open X

L6709 Term dev mech hand vol close X

L6711 Ped term dev, hook, vol open X

L6712 Ped term dev, hook, vol clos X

L6713 Ped term dev, hand, vol open X

L6714 Ped term dev, hand, vol clos X

L6721 Hook/hand, hvy dty, vol open X

L6722 Hook/hand, hvy dty, vol clos X

L6805 Term dev modifier wrist unit X

L6810 Term dev precision pinch dev X

L6881 Term dev auto grasp feature X

L6882 Microprocessor control uplmb X

L6883 Replc sockt below e/w disa X

L6884 Replc sockt above elbow disa X

L6885 Replc sockt shldr dis/interc X

L6890 Prefab glove for term device X

L6895 Custom glove for term device X

L6900 Hand restorat thumb/1 finger X

L6905 Hand restoration multiple fi X

L6910 Hand restoration no fingers X

L6915 Hand restoration replacmnt g X

L6920 Wrist disarticul switch ctrl X

L6925 Wrist disart myoelectronic c X

L6930 Below elbow switch control X

L6935 Below elbow myoelectronic ct X

L6940 Elbow disarticulation switch X

L6945 Elbow disart myoelectronic c X

L6950 Above elbow switch control X

L6955 Above elbow myoelectronic ct X

L6960 Shldr disartic switch contro X

L6965 Shldr disartic myoelectronic X

L6970 Interscapular-thor switch ct X

L6975 Interscap-thor myoelectronic X

L7007 Adult electric hand X

L7008 Pediatric electric hand X

L7009 Adult electric hook X

L7040 Prehensile actuator X

L7045 Pediatric electric hook X

L7170 Electronic elbow hosmer swit X

L7180 Electronic elbow sequential X

L7181 Electronic elbo simultaneous X

L7185 Electron elbow adolescent sw X

L7186 Electron elbow child switch X

L7190 Elbow adolescent myoelectron X

L7191 Elbow child myoelectronic ct X

L7260 Electron wrist rotator otto X

L7261 Electron wrist rotator utah X

L7266 Servo control steeper or equ X

L7272 Analogue control unb or equa X

L7274 Proportional ctl 12 volt uta X

L7360 Six volt bat otto bock/eq ea X

L7362 Battery chrgr six volt otto X

L7364 Twelve volt battery utah/equ X

42


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

L7366 Battery chrgr 12 volt utah/e X

L7367 Replacemnt lithium ionbatter X

L7368 Lithium ion battery charger X

L7400 Add UE prost be/wd, ultlite X

L7401 Add UE prost a/e ultlite mat X

L7402 Add UE prost s/d ultlite mat X

L7403 Add UE prost b/e acrylic X

L7404 Add UE prost a/e acrylic X

L7405 Add UE prost s/d acrylic X

L7900 Male vacuum erection system X

L8000 Mastectomy bra

L8001 Breast prosthesis bra & form

L8002 Brst prsth bra & bilat form

L8015 Ext breastprosthesis garment

L8020 Mastectomy form

L8030 Breast prosthes w/o adhesive

L8031 Breast prosthesis w adhesive

L8032 Reusable nipple prosthesis

L8035 Custom breast prosthesis

L8040 Nasal prosthesis X

L8040 KM Nasal prosthesis X

L8040 KN Nasal prosthesis X

L8041 Midfacial prosthesis X

L8041 KM Midfacial prosthesis X

L8041 KN Midfacial prosthesis X

L8042 Orbital prosthesis X

L8042 KM Orbital prosthesis X

L8042 KN Orbital prosthesis X

L8043 Upper facial prosthesis X

L8043 KM Upper facial prosthesis X

L8043 KN Upper facial prosthesis X

L8044 Hemi-facial prosthesis X

L8044 KM Hemi-facial prosthesis X

L8044 KN Hemi-facial prosthesis X

L8045 Auricular prosthesis X

L8045 KM Auricular prosthesis X

L8045 KN Auricular prosthesis X

L8046 Partial facial prosthesis X

L8046 KM Partial facial prosthesis X

L8046 KN Partial facial prosthesis X

L8047 Nasal septal prosthesis X

L8047 KM Nasal septal prosthesis X

L8047 KN Nasal septal prosthesis X

L8300 Truss single w/ standard pad X

L8310 Truss double w/ standard pad X

L8320 Truss addition to std pad wa X

L8330 Truss add to std pad scrotal X

L8400 Sheath below knee X

L8410 Sheath above knee X

L8415 Sheath upper limb X

L8417 Pros sheath/sock w gel cushn X

L8420 Prosthetic sock multi ply BK X

L8430 Prosthetic sock multi ply AK X

L8435 Pros sock multi ply upper lm X

L8440 Shrinker below knee X

L8460 Shrinker above knee X

43


2Descripción

Códigos con "X"

requieren

preautorización

Códigos con "X"

aplica coaseguro

según plan

L8465 Shrinker upper limb X

L8470 Pros sock single ply BK X

L8480 Pros sock single ply AK X

L8485 Pros sock single ply upper l X

L8500 Artificial larynx X

L8501 Tracheostomy speaking valve X

L8507 Trach-esoph voice pros pt in X

L8509 Trach-esoph voice pros md in X

L8510 Voice amplifier X

L8511 Indwelling trach insert X

L8512 Gel cap for trach voice pros X

L8513 Trach pros cleaning device X

L8514 Repl trach puncture dilator X

L8515 Gel cap app device for trach X

L8600 Implant breast silicone/eq X

L8603 Collagen imp urinary 2.5 ml X

L8606 Synthetic implnt urinary 1ml X

L8609 Artificial cornea X

L8610 Ocular implant X

L8612 Aqueous shunt prosthesis X

L8613 Ossicular implant X

L8614 Cochlear device X

L8615 Coch implant headset replace X

L8616 Coch implant microphone repl X

L8617 Coch implant trans coil repl X

L8618 Coch implant tran cable repl X

L8619 Coch imp ext proc/contr rplc X

L8621 Repl zinc air battery X

L8622 Repl alkaline battery X

L8623 Lith ion batt CID,non-earlvl X

L8624 Lith ion batt CID, ear level X

L8627 CID ext speech process repl X

L8628 CID ext controller repl X

L8629 CID transmit coil and cable X

L8630 Metacarpophalangeal implant X

L8631 MCP joint repl 2 pc or more X

L8641 Metatarsal joint implant X

L8642 Hallux implant X

L8658 Interphalangeal joint spacer X

L8659 Interphalangeal joint repl X

L8670 Vascular graft, synthetic X

L8680 Implt neurostim elctr each X

L8681 Pt prgrm for implt neurostim X

L8682 Implt neurostim radiofq rec X

L8683 Radiofq trsmtr for implt neu X

L8684 Radiof trsmtr implt scrl neu X

L8685 Implt nrostm pls gen sng rec X

L8686 Implt nrostm pls gen sng non X

L8687 Implt nrostm pls gen dua rec X

L8688 Implt nrostm pls gen dua non X

L8689 External recharg sys intern X

L8690 Aud osseo dev, int/ext comp X

L8691 Osseointegrated snd proc rpl X

L8693 Aud osseo dev, abutment X

L8695 External recharg sys extern X

44

CARTA CIRCULARpublicaciones.ssspr.com/Cartas/Documents/M1203073.pdf · CARTA CIRCULAR # M1203073 12...

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Transcript of CARTA CIRCULARpublicaciones.ssspr.com/Cartas/Documents/M1203073.pdf · CARTA CIRCULAR # M1203073 12...