APPENDIX 506A: COVERED DME SUPPLIES

APPENDIX 506A: COVERED DME SUPPLIES For additional information about durable medical equipment, please contact the DME policy manager. For additional information about home health SUPPLIES , please contact the Home Health policy manager. Page 1 of 79 DISCLAIMER: This chapter does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulations. Contact BMS Fiscal Agent for coverage, prior authorization requirements, service limitations, and other practitioner information. HCPCS CODES DESCRIPTION SERVICE LIMIT SPECIAL INSTRUCTIONS HOME HEALTH A4206 SYRINGE WITH NEEDLE, STERILE 1CC OR LESS, EACH 100 PER ROLLING MONTH A4207 SYRINGE WITH NEEDLE, STERILE 2CC, EACH 100 PER ROLLING MONTH A4208 SYRINGE WITH NEEDLE, STERILE 3CC, EACH 100 PER ROLLING MONTH A4209 SYRINGE WITH NEEDLE, STERILE 5CC OR GREATER, EACH 100 PER ROLLING MONTH A4213 SYRINGE, STERILE, 20 CC OR GREATER, EACH 60 PER ROLLING MONTH A4215 NEEDLE, STERILE, ANY SIZE EACH 100 PER ROLLING MONTH A4216 STERILE WATER, SALINE AND/OR DEXTROSE DILUENT/FLUSH, 10 ML A4217 STERILE WATER/SALINE, 500 ML COVERAGE LIMITED TO TRACHEAL SUCTIONING ONLY

supplies for maintenance of drug infusion catheter, per week (list drug separately) 4 per rolling month supplies include: heplock start kits, central line kits, insytes, etoh swabs, huber needles, sub-q- needle, sub-q kit non-reimbursable with: a4230 or a4231 a4222 infusion supplies for external drug infusion pump, per cassette or bag

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