DME PROCEDURE CODES AND COVERAGE GUIDELINES
equipment provider should supply the accessory or component at no additional charge to the member. 4.1 MEDICAL/SURGICAL SUPPLIES . ADHESIVE TAPE/REMOVER . A4450 Tape, non-waterproof, per 18 square inches (up to 300) A4452 Tape, waterproof, per 18 square inches (up to 100) A4455 Adhesive remover or solvent (for tape, cement or other adhesive ...
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