REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 1 ******************************************************************************* KEY TO DME INDEX/MAF REPORT ******************************************************************************* ATTACHED IS THE WISCONSIN MEDICAID PROGRAM DME INDEX/MAXIMUM ALLOWABLE FEE SCHEDULE. THIS DME INDEX/MAFS COMPLETELY REPLACES PRIOR DME INDICES. WISCONSIN MEDICAID CERTIFIED PROVIDERS ARE REIMBURSED FOR SERVICES PROVIDED TO PROGRAM RECIPIENTS AT THE LOWER OF THEIR CUSTOMARY CHARGE OR THE MAXIMUM ALLOWABLE FEE, IN ACCORDANCE WITH THE TERMS OF REIMBURSEMENT. NOTE: BADGERCARE PLUS BENCHMARK PLAN MEMBERS WILL BE RESPONSIBLE FOR A $5.00 COPAYMENT PER ITEM. RENTALS ARE EXEMPT FROM COPAY. WISCONSIN MEDICAID UTILIZES HCPCS NATIONAL LEVEL II CODES DEVELOPED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS). PROVIDERS USING THE PROCEDURE CODES LISTED IN THIS INDEX MUST SELECT THE PROCEDURE CODES THAT MOST ACCURATELY IDENTIFY THE EQUIPMENT OR SERVICE ORDERED BY THE PHYSICIAN AND DELIVERED. MOST PROCEDURE CODES LISTED IN THIS INDEX ARE INCLUSIVE OF ALL COMPONENTS NECESSARY TO THE FUNCTIONING OF THE PART OR EQUIPMENT. BILLING ADDITIONALLY OR SEPARATELY FOR THESE COMPONENTS WHEN PROVIDED AT THE SAME TIME COULD RESULT IN DENIALS FROM WISCONSIN MEDICAID WHEN THERE EXISTS A MORE INCLUSIVE CODE. WISCONSIN ADMINISTRATIVE CODE HFS 107.24(B) STATES COVERED SERVICES ARE LIMITED TO ITEMS CONTAINED IN THE WISCONSIN DURABLE MEDICAL EQUIPMENT (DME) AND MEDICAL SUPPLIES INDICES. ITEMS PRESCRIBED BY A PHYSICIAN WHICH ARE NOT CONTAINED IN THESE INDICES REQUIRE PRIOR AUTHORIZATION FOR CONSIDERATION OF COVERAGE. THESE ITEMS MAY BE REQUESTED USING THE APPROPRIATE "NOT OTHERWISE CLASSIFIED CODE" (NOC). HOWEVER, DOCUMENTATION MUST INCLUDE A COMPLETE DESCRIPTION OF THE NATURE, EXTENT, AND NEED FOR THE SERVICE OR EQUIPMENT. PRIOR TO USING AN UNLISTED PROCEDURE CODE YOU MUST DETERMINE IF A SPECIFIC HCPCS CODE IS NOT AVAILABLE FOR USE. IF YOU HAVE QUESTIONS REGARDING THE INFORMATION ATTACHED, PLEASE CONTACT THE DHCAA POLICY UNIT BY WRITING TO: DME POLICY ANALYST POLICY SECTION DHCAA, P.O. BOX 309 MADISON, WI 53701-0309 DME INDEX/MAXIMUM ALLOWABLE FEE SCHEDULES ARE AVAILABLE ON THE WISCONSIN MEDICAID WEBSITE IN EXE, PDF, TXT, AND INTERACTIVE FORMATS. THE INDICES ARE ALSO AVAILABLE ON THE EDS-EPIX PC BULLETIN BOARD, MICROFICHE, TAPE CARTRIDGE, MAGNETIC TAPE AND DISKETTE. REFER TO PART A OF YOUR PROVIDER HANDBOOK FOR ADDITIONAL INFORMATION. REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 2 FIELD HEADING DESCRIPTION ------------------------------------------------------------------------------- PROC CODE 5-CHARACTER HCPCS PROCEDURE CODE. IF A SPACE AND MODIFIER RR DISPLAY AFTER THE PROCEDURE CODE, THE ITEM IS A RENTAL. IF NO RR MODIFIER DISPLAYS AFTER THE PROCEDURE CODE, THE ITEM IS A PURCHASE. IF THE PROCEDURE CODE IS FOLLOWED BY A DASH AND TWO DIGITS, THE PROCEDURE CODE REQUIRES THE USE OF THE NATIONAL MODIFIER INDICATED. NOTE: ALL RENTAL PAYMENTS PAID TO THE SAME PROVIDER ARE DEDUCTED FROM THE MAXIMUM ALLOWABLE REIMBURSEMENT FOR THE SUBSEQUENT PURCHASE. PAC 3-CHARACTER PRICING ACTION CODE. 170 - PAID AT THE LOWER OF THE BILLED AMOUNT OR MAXIMUM ALLOWABLE FEE 11J - INDIVIDUAL CONSIDERATION, MEDICAL CONSULTANT REVIEW 1F0 - INDIVIDUAL CONSIDERATION MAX FEE MAXIMUM ALLOWABLE FEE. EFF DATE THE DATE OF SERVICE ON OR AFTER WHICH THE MAXIMUM ALLOWABLE FEE APPLIES. FULL DESC THE COMPLETE DESCRIPTION OF A PROCEDURE CODE. POS THE PLACE OF SERVICE CODES A PROCEDURE CAN BE PROVIDED IN. 11 - OFFICE 12 - HOME 22 - OUTPATIENT HOSPITAL 24 - AMBULATORY SURGICAL CENTER 31 - SKILLED NURSING FACILITY 32 - NURSING FACILITY 99 - OTHER PLACE OF SERVICE NOTE: ITEMS PROVIDED IN POS 31 AND 32 MAY BE SEPARATELY BILLED TO WISCONSIN MEDICAID ONLY IF "Y" IS INDICATED IN THE NH FIELD. REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 3 PROV TYPES THE VALID OR INVALID PROVIDER TYPES FOR A PROCEDURE CODE. 24 - FQHC 26 - PHARMACY 30 - CHIROPRACTIC 34 - PHYSICAL THERAPISTS 35 - OCCUPATIONAL THERAPISTS 36 - SPEECH AND HEARING CLINICS 37 - AUDIOLOGIST 38 - THERAPY GROUP 44 - HOME HEALTH AGENCY 45 - NURSE PRACTITIONER 48 - HOME HEALTH/PERSONAL CARE DUALLY CERTIFIED 54 - DURABLE MEDICAL EQUIPMENT VENDOR 58 - OTHER MEDICAL SUPPLIER 65 - REHABILITATION AGENCY 78 - SPEECH THERAPY 79 - ICF/MR FACILITY 80 - NURSING FACILITY 95 - HOSPICE BI BILATERAL INDICATOR. A "Y" INDICATES THAT THE ITEM MAY BE BILLED SINGLY OR AS A PAIR. AN "N" INDICATES THAT THE ITEM MAY NOT BE BILLED AS BILATERAL. IF BILATERAL ITEMS ARE BILLED FOR THE SAME DATE OF SERVICE, A QUANTITY OF "2" OR MORE MUST BE USED. IF BILATERAL ITEMS ARE PROVIDED ON DIFFERENT DATES OF SERVICE, THE "50" MODIFIER MUST BE INDICATED WITH THE PROCEDURE CODE OF THE ADDITIONAL ITEM BILLED. PA REQ PRIOR AUTHORIZATION REQUIREMENT INDICATORS. Y INITIAL PURCHASE OR INITIAL RENTAL OF THE DME ITEM REQUIRES PRIOR AUTHORIZATION 30 RENTAL OF THE DME ITEM BEYOND 30 DAYS REQUIRES PRIOR AUTHORIZATION. 60 RENTAL OF THE DME ITEM BEYOND 60 DAYS REQUIRES PRIOR AUTHORIZATION. 90 RENTAL OF THE DME ITEM BEYOND 90 DAYS REQUIRES PRIOR AUTHORIZATION. 180 RENTAL OF THE DME ITEM BEYOND 180 DAYS REQUIRES PRIOR AUTHORIZATION. $ CHARGES EXCEEDING THE SPECIFIED DOLLAR AMOUNT FOR A COMPLETE SERVICE/ITEM REQUIRES PRIOR AUTHORIZATION. N INITIAL PURCHASE OR INITIAL RENTAL OF A DME ITEM DOES NOT REQUIRE PRIOR AUTHORIZATION. REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 4 LIFE EXP INDICATES THE EXPECTED LIFE OF THE ITEM. PRIOR AUTHORIZATION IS REQUIRED IF THE DME ITEM NEEDS TO BE REPLACED BEFORE THE END OF ITS EXPECTED LIFE. NH A "Y" INDICATES THE DME ITEM MAY BE SEPARATELY BILLED TO WISCONSIN MEDICAID FOR NURSING HOME RECIPIENTS. AN "N" INDICATES THE DME ITEM MAY NOT BE BILLED SEPARATELY TO WISCONSIN MEDICAID FOR NURSING HOME RECIPIENTS. NOTE: MANUAL WHEELCHAIR RENTALS (MODIFIER RR) ARE NOT SEPARATELY REIMBURSABLE TO NURSING HOME RECIPIENTS. MANUAL/POWER/MOTORIZED WHEELCHAIR AND ACCESSORY PURCHASES ARE SEPARATELY REIMBURSABLE TO NURSING HOME RECIPIENTS ONLY UNDER LIMITED CONDITIONS. SEE YOUR WISCONSIN MEDICAID PROVIDER HANDBOOK, PART N, AND WISCONSIN MEDICAID UPDATES FOR FOR THESE SPECIAL CIRCUMSTANCES. COPAY INDICATES THE COPAYMENT ON DME PURCHASES. IF SEVERAL SERVICES ARE PERFORMED DURING ONE VISIT, MORE THAN ONE COPAY MAY APPLY. REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 5 ======================================================================== DME INDEX/MAFS CATEGORIES HOME HEALTH EQUIPMENT AMBULATION EQUIPMENT-CANES CRUTCHES WALKERS ATTACHMENTS: CANES, CRUTCHES, WALKERS BATH AND TOILET AIDS COMMODES DECUBITUS CARE EQUIPMENT HEAT AND COLD APPLICATION HOSPITAL BEDS MATTRESSES BED ACCESSORIES BED PANS/URINALS MONITORING EQUIPMENT COMMUNICATION DEVICES PATIENT LIFTS PNEUMATIC EQUIPMENT ELECTROTHERAPY MODALITIES PUMPS TRACTION AND RELATED EQUIPMENT-CERVICAL TRACTION EQUIPMENT-OVERDOOR TRACTION EQUIPMENT-EXTREMITY TRACTION EQUIPMENT-PELVIC TRAPEZE EQUIPMENT, FRACTURE FRAME AND OTHER ORTHOPEDIC DEVICES ADAPTIVE EQUIPMENT POSITIONING EQUIPMENT MISCELLANEOUS DME AND REPAIR RESPIRATORY EQUIPMENT OXYGEN CONTENTS OXYGEN AND RELATED RESPIRATORY SYSTEMS ADDITIONAL OXYGEN RELATED SUPPLIES AND EQUIPMENT CONCENTRATORS OXYGEN ENRICHER SYSTEMS IPPB HUMIDIFIERS COMPRESSORS NEBULIZERS SUCTION PUMP/ROOM VAPORIZERS AND RELATED EQUIPMENT SUPPLIES-OXYGEN/RELATED RESPIRATORY EQUIPMENT-VENTILATORS/RESPIRATORS MISCELLANEOUS-OXYGEN/RELATED RESPIRATORY EQUIPMENT OXYGEN TENTS MONITORS-CARDIOPULMONARY REPAIRS-OXYGEN THERAPY EQUIPMENT WHEELCHAIRS AND WHEELCHAIR ACCESSORIES WHEELCHAIR ACCESSORIES WHEELCHAIR-STANDARD WHEELCHAIR-LIGHTWEIGHT WHEELCHAIR-HEAVY DUTY WHEELCHAIR-WIDE HEAVY DUTY WHEELCHAIR-HEMI WHEELCHAIR-HIGH STRENGTH WHEELCHAIR-SEMI RECLINING WHEELCHAIR-FULLY RECLINING WHEELCHAIR-AMPUTEE REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 6 WHEELCHAIR-ONE ARM DRIVE WHEELCHAIR-MISCELLANEOUS MOTORIZED WHEELCHAIR BATTERIES-WHEELCHAIRS ORTHOTIC DEVICES SPINAL-CERVICAL SPINAL-THORACIC SPINAL-THORACIC-LUMBAR-SACRAL-FLEXIBLE ANTERIOR-POSTERIOR CONTROL ANTERIOR-POSTERIOR-LATERAL-ROTARY CONTROL SPINAL-LUMBAR SACRAL-FLEXIBLE ANTERIOR-POSTERIOR-LATERAL CONTROL ANTERIOR-POSTERIOR CONTROL LUMBAR FLEXION ANTERIOR-POSTERIOR-LATERAL CONTROL (BODY JACKET) SPINAL-SACRIOLIAC-FLEXIBLE SEMI-RIGID SPINAL-CERVICAL-THORACIC-LUMBAR-SACRAL-HALO-ANTERIOR-POSTERIOR-LATERAL HALO PROCEDURE SPINAL-TORSO SUPPORTS-PTOSIS SUPPORTS PENDULOUS ABDOMEN SUPPORT POST SURGICAL SUPPORT ADDITIONS TO SPINAL ORTHOSES SCOLIOSIS PROCEDURES-SCOLIOSIS-CERVICAL-THORACIC-LUMBAR-SACRAL CORRECTION PADS SCOLIOSIS-THORACIC-LUMBAR-SACRAL (LOW PROFILE) OTHER SCOLIOSIS PROCEDURES THORACIC-HIP-KNEE-ANKLE LOWER LIMB-HIP-FLEXIBLE LEGG PERTHES KNEE ANKLE-FOOT HIP-KNEE-ANKLE-FOOT TORSION CONTROL FRACTURE ORTHOSES ADDITIONS TO FRACTURE ORTHOSIS ADDITIONS TO LOWER EXTREMITY ORTHOSIS-ADDITIONS-SHOE-ANKLE-SHIN-KNEE ADDITIONS TO STRAIGHT OR OFFSET KNEE JOINTS ADDITIONS-THIGH/WEIGHT BEARING-GLUTEAL/ISCHIAL WEIGHT ADDITIONS-PELVIC AND THORACIC CONTROL ADDITIONS-GENERAL-LOWER EXTREMITY ORTHOPEDIC SHOES, MODIFICATIONS, TRANSFERS INSERT, REMOVABLE, MOLDED TO PATIENT MODEL ARCH SUPPORT, REMOVABLE PREMOLDED ARCH SUPPORT, NON-REMOVABLE, ATTACHED TO SHOE ABDUCTION AND ROTATION BARS ORTHOPEDIC FOOTWEAR SHOE MODIFICATION-LIFTS SHOE MODIFICATION-WEDGES SHOE MODIFICATION-HEELS MISCELLANEOUS SHOE ADDITIONS TRANSFER OR REPLACEMENT DIABETIC SHOE SUPPLIES REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 7 ORTHOTIC DEVICES UPPER LIMB-SHOULDER ELBOW WRIST-HAND-FINGER ADDITIONS-UPPER LIMB DYNAMIC ADJUSTABLE EXTENSION/FLEXION DEVICES EXTERNAL POWER OTHER WRIST-HAND-FINGER ORTHOSES-CUSTOM FITTED UPPER LIMB-SHOULDER-ELBOW-WRIST-HAND-ABDUCTION POSITIONING-CUSTOM FIT ADDITIONS TO MOBILE ARM SUPPORT FRACTURE ORTHOSES SPECIFIC REPAIR-ORTHOSES REPAIRS-ORTHOTIC ANCILLARY ORTHOTIC SERVICES PROSTHETIC PROCEDURES LOWER LIMB-PARTIAL FOOT ANKLE BELOW KNEE KNEE DISARTICULATION ABOVE KNEE HIP DISARTICULATION HEMIPELVECTOMY ENDOSKELETAL-BELOW KNEE ENDOSKELETAL-KNEE DISARTICULATION ENDOSKELETAL-ABOVE KNEE ENDOSKELETAL-HIP DISARTICULATION ENDOSKELETAL-HEMIPELVECTOMY IMMEDIATE-EARLY-INITIAL-PREPARATORY/POST SURGICAL/FITTING PROCEDURES INITIAL PROSTHESIS PREPARATORY PROSTHESIS ADDITIONS TO LOWER EXTREMITY TEST SOCKETS SOCKET VARIATIONS SOCKET INSERT AND SUSPENSION ADDITIONS-KNEE-SHIN-SYSTEM-EXOSKELETAL ADDITIONS-KNEE-SHIN SYSTEM-ENDOSKELETAL UPPER LIMB-PARTIAL HAND WRIST DISARTICULATION BELOW ELBOW ELBOW DISARTICULATION ABOVE ELBOW SHOULDER DISARTICULATION INTERSCAPULAR THORACIC IMMEDIATE AND EARLY POST SURGICAL ENDOSKELETAL-BELOW ELBOW ENDOSKELETAL-ELBOW DISARTICULATION ENDOSKELETAL-ABOVE ELBOW ENDOSKELETAL-SHOULDER DISARTICULATION ENDOSKELETAL-INTERSCAPULAR THORACIC ADDITIONS TO UPPER EXTREMITY TERMINAL DEVICES-HOOKS TERMINAL DEVICES-HANDS GLOVES FOR ABOVE HANDS HAND RESTORATION EXTERNAL POWER-BASE DEVICES EXTERNAL POWER-TERMINAL DEVICES EXTERNAL POWER-ELBOW EXTERNAL POWER-CONTROL MODULES EXTERNAL POWER-BATTERY COMPONENTS REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 8 REPAIRS-PROSTHETIC GENERAL-PROSTHESES ELASTIC-SUPPORTS TRUSSES PROSTHETIC SOCKS IMPLANTS PROSTHETIC IMPLANTS INTEGUMENTARY SYSTEM HEAD-SKULL-FACIAL BONES-TEMPOROMANDIBULAR JOINT UPPER EXTREMITY LOWER EXTREMITY MISCELLANEOUS MUSCULAR CARDIOVASCULAR SYSTEM OTHER IMPLANTS REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 9 ======================================================================= DME INDEX MODIFIERS LT- EFFECTIVE FOR DATES OF SERVICE ON OR AFTER 01/01/07. MODIFIER USED TO INDICATE LEFT SIDE OF BODY. RP- EFFECTIVE FOR DATES OF SERVICE ON OR AFTER 10/01/03, PROVIDERS MAY USE THE RP MODIFIER (REPAIR AND MODIFICATION) WHEN SUBMITTING CLAIMS FOR MISCELLANEOUS REPAIR PARTS FOR THE FOLLOWING PROCEDURE CODE RANGES FOR PURCHASE ONLY: WHEELCHAIRS: E1230 E1230 - 59 K0001 - K0012 K0014 HOSPITAL E0250 - E0251 BEDS: E0255 - E0256 E0260 - E0261 E0265 - E0266 E0290 - E0297 E0301 - E0304 LIFTS: E0630 E0635 COMMODE E0163 - E0164 CHAIRS: E0168 E0240 E0247 RR- USED TO INDICATE RENTAL. RT- EFFECTIVE FOR DATES OF SERVICE ON OR AFTER 01/01/07. MODIFIER USED TO INDICATE RIGHT SIDE OF BODY. TW- USED TO INDICATE BACKUP/SECONDARY EQUIPMENT. PAYS 50% OF CURRENT MAXIMUM ALLOWABLE FEE AND IS AVAILABLE ON CERTAIN CODES. PLEASE SEE PROVIDER UPDATE 2004-36 FOR MORE INFORMATION. QE- INDICATES OXYGEN FLOW LESS THAN ONE LITER PER MINUTE. QG- INDICATES OXYGEN FLOW MORE THAN FOUR LITERS PER MINUTE. 59- INDICATES DISTINCT PROCEDURAL SERVICE. 52- INDICATES REDUCED SERVICES. REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 10 VALID DME PROCEDURE CODES WITH MODIFIERS A6530-LT PAC: 170 MAX FEE: $ 8.55 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $0.50 A6530-RT PAC: 170 MAX FEE: $ 8.55 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $0.50 A6531-LT PAC: 170 MAX FEE: $ 23.85 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $1.00 A6531-RT PAC: 170 MAX FEE: $ 23.85 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $1.00 A6532-LT PAC: 170 MAX FEE: $ 41.76 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $2.00 A6532-RT PAC: 170 MAX FEE: $ 41.76 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $2.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 11 VALID DME PROCEDURE CODES WITH MODIFIERS A6533-LT PAC: 170 MAX FEE: $ 45.94 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $2.00 A6533-RT PAC: 170 MAX FEE: $ 45.94 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $2.00 A6534-LT PAC: 170 MAX FEE: $ 46.99 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $2.00 A6534-RT PAC: 170 MAX FEE: $ 46.99 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $2.00 A6535-LT PAC: 170 MAX FEE: $ 64.73 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 A6535-RT PAC: 170 MAX FEE: $ 64.73 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 12 VALID DME PROCEDURE CODES WITH MODIFIERS A6536-LT PAC: 170 MAX FEE: $ 52.21 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 A6536-RT PAC: 170 MAX FEE: $ 52.21 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 A6537-LT PAC: 170 MAX FEE: $ 73.08 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 A6537-RT PAC: 170 MAX FEE: $ 73.08 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 A6538-LT PAC: 170 MAX FEE: $ 73.08 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40-50 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 A6538-RT PAC: 170 MAX FEE: $ 73.08 EFF DATE: 02/01/07 FULL DESC: GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40-50 MMHG, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 13 VALID DME PROCEDURE CODES WITH MODIFIERS A9900-UA PAC: 170 MAX FEE: $ 4.50 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $0.50 A9900-UB PAC: 170 MAX FEE: $ 4.50 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $0.50 A9900-UC PAC: 170 MAX FEE: $ 30.60 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 8 YEARS NH: Y COPAY: $0.50 A9900-UD PAC: 170 MAX FEE: $ 5.50 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1-3 YEARS NH: Y COPAY: $0.50 A9900-U1 PAC: 170 MAX FEE: $ 7.25 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER 2 YRS NH: Y COPAY: $0.50 A9900-U2 PAC: 170 MAX FEE: $ 6.25 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER 2 YRS NH: Y COPAY: $0.50 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 14 VALID DME PROCEDURE CODES WITH MODIFIERS A9900-U3 PAC: 170 MAX FEE: $ 12.24 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $0.50 A9900-U4 PAC: 170 MAX FEE: $ 7.50 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: Y COPAY: $0.50 A9900-U5 PAC: 170 MAX FEE: $ 15.00 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $0.50 A9900-U6 PAC: 170 MAX FEE: $ 6.50 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: Y COPAY: $0.50 A9900-U7 PAC: 170 MAX FEE: $ 8.75 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 4 YEARS NH: Y COPAY: $0.50 A9900-U9 PAC: 170 MAX FEE: $ 8.50 EFF DATE: 09/01/05 FULL DESC: MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: Y COPAY: $0.50 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 15 VALID DME PROCEDURE CODES WITH MODIFIERS E0424-QE RR PAC: 170 MAX FEE: $ 3.40 EFF DATE: 12/01/03 FULL DESC: STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM; RENTAL, INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASKS AND TUBING (PRESCRIBED AMOUNT OF OXYGEN IS LESS THAN ONE LITER PER MINUTE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 44 48 54 58 65 79 80 95 BI: N PA REQ: 30 LIFE EXP: NH: Y COPAY: $0.00 E0424-QG RR PAC: 170 MAX FEE: $ 10.20 EFF DATE: 12/01/03 FULL DESC: STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM; RENTAL, INCLUDES CONTAINER, CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASKS AND TUBING (PRESCRIBED AMOUNT OF OXYGEN IS GREATER THAN FOUR LITERS PER MINUTE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 44 48 54 58 65 79 80 95 BI: N PA REQ: 30 LIFE EXP: NH: Y COPAY: $0.00 E0439-QE RR PAC: 170 MAX FEE: $ 3.40 EFF DATE: 12/01/03 FULL DESC: STATIONARY LIQUID OXYGEN SYSTEM; RENTAL, INCLUDES CONTAINER CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASKS, AND TUBING (PRESCRIBED AMOUNT OF OXYGEN IS LESS THAN ONE LITER PER MINUTE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 44 48 54 58 65 79 80 95 BI: N PA REQ: 30 LIFE EXP: NH: Y COPAY: $0.00 E0439-QG RR PAC: 170 MAX FEE: $ 10.20 EFF DATE: 12/01/03 FULL DESC: STATIONARY LIQUID OXYGEN SYSTEM; RENTAL, INCLUDES CONTAINER CONTENTS, REGULATOR, FLOWMETER, HUMIDIFIER, NEBULIZER, CANNULA OR MASKS AND TUBING (PRESCRIBED AMOUNT OF OXYGEN IS GREATER THAN FOUR LITERS PER MINUTE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 44 48 54 58 65 79 80 95 BI: N PA REQ: 30 LIFE EXP: NH: Y COPAY: $0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 16 VALID DME PROCEDURE CODES WITH MODIFIERS E0450-52 RR PAC: 170 MAX FEE: $ 7.75 EFF DATE: 01/01/04 FULL DESC: VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH INVASIVE INTERFACE (E.G., TRACHEOSTOMY TUBE), REDUCED SERVICES POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: Y COPAY: $0.00 E0463-52 RR PAC: 170 MAX FEE: $ 9.05 EFF DATE: 01/01/05 FULL DESC: PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH INVASIVE INTERFACE (E.G. TRACHEOSTOMY TUBE), REDUCED SERVICES POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $0.00 E0464-52 RR PAC: 170 MAX FEE: $ 9.05 EFF DATE: 01/01/05 FULL DESC: PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK), REDUCED SERVICES POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $0.00 E0472-52 RR PAC: 170 MAX FEE: $ 6.72 EFF DATE: 01/01/04 FULL DESC: RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH INVASIVE INTERFACE, E.G., TRACHEOSTOMY TUBE (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE), REDUCED SERVICES POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: Y COPAY: $0.00 E0621-59 PAC: 170 MAX FEE: $ 85.89 EFF DATE: 10/01/03 FULL DESC: SLING OR SEAT, PATIENT LIFT, CANVAS OR NYLON, WITH COMMODE OPENING POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: N COPAY: $2.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 17 VALID DME PROCEDURE CODES WITH MODIFIERS E1390-QE RR PAC: 170 MAX FEE: $ 3.40 EFF DATE: 12/01/03 FULL DESC: OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE (PRESCRIBED AMOUNT OF OXYGEN IS LESS THAN ONE LITER PER MINUTE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 44 48 54 58 65 79 80 95 BI: N PA REQ: 30 LIFE EXP: NH: Y COPAY: $0.00 E1390-QG RR PAC: 170 MAX FEE: $ 10.20 EFF DATE: 12/01/03 FULL DESC: OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE (PRESCRIBED AMOUNT OF OXYGEN IS GREATER THAN FOUR LITERS PER MINUTE) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 44 48 54 58 65 79 80 95 BI: N PA REQ: 30 LIFE EXP: NH: Y COPAY: $0.00 S8421-LT PAC: 170 MAX FEE: $ 72.95 EFF DATE: 02/01/07 FULL DESC: GRADIENT PRESSURE AID (SLEEVE AND GLOVE COMBINATION), READY MADE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 S8421-RT PAC: 170 MAX FEE: $ 72.95 EFF DATE: 02/01/07 FULL DESC: GRADIENT PRESSURE AID (SLEEVE AND GLOVE COMBINATION), READY MADE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 S8424-LT PAC: 170 MAX FEE: $ 58.37 EFF DATE: 02/01/07 FULL DESC: GRADIENT PRESSURE AID (SLEEVE), READY MADE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 S8424-RT PAC: 170 MAX FEE: $ 58.37 EFF DATE: 02/01/07 FULL DESC: GRADIENT PRESSURE AID (SLEEVE), READY MADE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 18 VALID DME PROCEDURE CODES WITH MODIFIERS S8427-LT PAC: 170 MAX FEE: $ 179.95 EFF DATE: 02/01/07 FULL DESC: GRADIENT PRESSURE AID (GLOVE), READY MADE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 S8427-RT PAC: 170 MAX FEE: $ 179.95 EFF DATE: 02/01/07 FULL DESC: GRADIENT PRESSURE AID (GLOVE), READY MADE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 S8428-LT PAC: 170 MAX FEE: $ 36.93 EFF DATE: 02/01/07 FULL DESC: GRADIENT PRESSURE AID (GAUNTLET), READY MADE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 S8428-RT PAC: 170 MAX FEE: $ 36.93 EFF DATE: 02/01/07 FULL DESC: GRADIENT PRESSURE AID (GAUNTLET), READY MADE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 PER YEAR NH: Y COPAY: $3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 19 ******************************************************************************* HOME HEALTH EQUIPMENT ******************************************************************************* ------------------------------------------------------------------------------- + AMBULATION EQUIPMENT - CANES ------------------------------------------------------------------------------- E0100 PAC: 170 MAX FEE: $ 18.79 EFF DATE: 07/01/02 FULL DESC:CANE, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIP POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 4 YEARS NH: N COPAY: $ 1.00 E0105 PAC: 170 MAX FEE: $ 36.96 EFF DATE: 07/01/02 FULL DESC:CANE, QUAD OR THREE PRONG, INCLUDES CANES OF ALL MATERIALS, ADJUSTABLE OR FIXED, WITH TIPS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 2.00 ------------------------------------------------------------------------------- + CRUTCHES ------------------------------------------------------------------------------- E0110 PAC: 170 MAX FEE: $ 71.00 EFF DATE: 07/01/02 FULL DESC:CRUTCHES,FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED; PAIR COMPLETE WITH TIPS AND HANDGRIP POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0111 PAC: 170 MAX FEE: $ 19.12 EFF DATE: 07/01/02 FULL DESC:CRUTCH, FOREARM, INCLUDES CRUTCHES OF VARIOUS MATERIALS, ADJUSTABLE OR FIXED; EACH WITH TIP AND HANDGRIP POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 4 YEARS NH: N COPAY: $ 1.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 20 E0112 PAC: 170 MAX FEE: $ 30.42 EFF DATE: 07/01/02 FULL DESC:CRUTCHES, UNDERARM, WOOD, ADJUSTABLE OR FIXED; PAIR WITH PADS, TIPS AND HANDGRIP POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0113 PAC: 170 MAX FEE: $ 17.37 EFF DATE: 07/01/02 FULL DESC:CRUTCH UNDERARM, WOOD, ADJUSTABLE OR FIXED; EACH WITH PAD, TIP AND HANDGRIP POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 2.00 E0114 PAC: 170 MAX FEE: $ 40.59 EFF DATE: 07/01/02 FULL DESC:CRUTCHES, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, PAIR, WITH PADS, TIPS AND HANDGRIPS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 2.00 E0116 PAC: 170 MAX FEE: $ 22.81 EFF DATE: 07/01/02 FULL DESC:CRUTCH, UNDERARM, OTHER THAN WOOD, ADJUSTABLE OR FIXED, WITH PAD, TIP, HANDGRIP, WITH OR WITHOUT SHOCK ABSORBER, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 0.50 ------------------------------------------------------------------------------- + WALKERS ------------------------------------------------------------------------------- E0130 PAC: 170 MAX FEE: $ 57.74 EFF DATE: 07/01/02 FULL DESC:WALKER, RIGID (PICKUP), ADJUSTABLE OR FIXED HEIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 21 E0130 RR PAC: 170 MAX FEE: $ 0.27 EFF DATE: 07/01/01 FULL DESC:WALKER, RIGID (PICKUP), ADJUSTABLE OF FIXED HEIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0135 PAC: 170 MAX FEE: $ 72.97 EFF DATE: 07/01/02 FULL DESC:WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0135 RR PAC: 170 MAX FEE: $ 0.32 EFF DATE: 07/01/01 FULL DESC:WALKER, FOLDING (PICKUP), ADJUSTABLE OR FIXED HEIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0140 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 12/01/04 FULL DESC:WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, ANY TYPE POS: 12 PROV TYPES: VALID 24 34 38 44 48 54 65 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0140 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 12/01/04 FULL DESC:WALKER, WITH TRUNK SUPPORT, ADJUSTABLE OR FIXED HEIGHT, ANY TYPE POS: 12 PROV TYPES: VALID 24 34 38 44 48 54 65 BI: N PA REQ: Y LIFE EXP: NH: N COPAY: $ 0.00 E0141 PAC: 170 MAX FEE: $ 100.36 EFF DATE: 07/01/02 FULL DESC:WALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 22 E0141 RR PAC: 170 MAX FEE: $ 0.45 EFF DATE: 07/01/01 FULL DESC:WALKER, RIGID, WHEELED, ADJUSTABLE OR FIXED HEIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0143 PAC: 170 MAX FEE: $ 116.28 EFF DATE: 10/01/03 FULL DESC:WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0143 RR PAC: 170 MAX FEE: $ 0.45 EFF DATE: 10/01/03 FULL DESC:WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0147 PAC: 170 MAX FEE: $ 357.60 EFF DATE: 07/01/02 FULL DESC:WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0147 RR PAC: 170 MAX FEE: $ 1.19 EFF DATE: 07/01/02 FULL DESC:WALKER, HEAVY DUTY, MULTIPLE BRAKING SYSTEM, VARIABLE WHEEL RESISTANCE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0148 PAC: 170 MAX FEE: $ 121.31 EFF DATE: 07/01/02 FULL DESC:WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 23 E0148 RR PAC: 170 MAX FEE: $ 0.40 EFF DATE: 09/01/01 FULL DESC:WALKER, HEAVY DUTY, WITHOUT WHEELS, RIGID OR FOLDING, ANY TYPE, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0149 PAC: 170 MAX FEE: $ 215.22 EFF DATE: 07/01/02 FULL DESC:WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0149 RR PAC: 170 MAX FEE: $ 0.72 EFF DATE: 07/01/02 FULL DESC:WALKER, HEAVY DUTY, WHEELED, RIGID OR FOLDING, ANY TYPE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + ATTACHMENTS: CANES, CRUTCHES, WALKERS ------------------------------------------------------------------------------- A4635 PAC: 170 MAX FEE: $ 4.50 EFF DATE: 07/01/02 FULL DESC:UNDERARM PAD, CRUTCH, REPLACEMENT, EACH POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: N COPAY: $ 0.50 A4636 PAC: 170 MAX FEE: $ 3.70 EFF DATE: 07/01/02 FULL DESC:REPLACEMENT, HANDGRIP, CANE, CRUTCH, WALKER, EACH POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 2 PER YEAR NH: N COPAY: $ 0.50 A4637 PAC: 170 MAX FEE: $ 1.86 EFF DATE: 07/01/02 FULL DESC:REPLACEMENT, TIP, CANE, CRUTCH, OR WALKER, EACH POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 1 PER YEAR NH: N COPAY: $ 0.50 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 24 E0153 PAC: 170 MAX FEE: $ 58.38 EFF DATE: 07/01/02 FULL DESC:PLATFORM ATTACHMENT; FOREARM CRUTCH, EACH POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 2.00 E0154 PAC: 170 MAX FEE: $ 59.19 EFF DATE: 07/01/02 FULL DESC:PLATFORM ATTACHMENT; WALKER, EACH POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0155 PAC: 170 MAX FEE: $ 27.48 EFF DATE: 07/01/02 FULL DESC:WHEEL ATTACHMENT, RIGID PICK-UP WALKER, PER PAIR POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 4 YEARS NH: N COPAY: $ 1.00 E0156 PAC: 170 MAX FEE: $ 21.90 EFF DATE: 07/01/02 FULL DESC:SEAT ATTACHMENT, WALKER POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 1.00 E0157 PAC: 170 MAX FEE: $ 59.19 EFF DATE: 07/01/02 FULL DESC:CRUTCH ATTACHMENT, WALKER, EACH POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0158 PAC: 170 MAX FEE: $ 26.48 EFF DATE: 07/01/02 FULL DESC:LEG EXTENSIONS FOR WALKER, PER SET OF FOUR (4) POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 1.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 25 E0159 PAC: 170 MAX FEE: $ 17.89 EFF DATE: 07/01/02 FULL DESC:BRAKE ATTACHMENT FOR WHEELED WALKER, REPLACEMENT, EACH POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 1.00 ------------------------------------------------------------------------------- + BATH AND TOILET AIDS ------------------------------------------------------------------------------- E0240 PAC: 170 MAX FEE: $ 825.55 EFF DATE: 01/01/04 FULL DESC:BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0241 PAC: 170 MAX FEE: $ 26.64 EFF DATE: 10/01/03 FULL DESC:BATH TUB WALL RAIL, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 PER LIFETIME NH: N COPAY: $ 2.00 E0242 PAC: 170 MAX FEE: $ 26.64 EFF DATE: 10/01/03 FULL DESC:BATH TUB RAIL, FLOOR BASE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 PER LIFETIME NH: N COPAY: $ 2.00 E0243 PAC: 170 MAX FEE: $ 17.54 EFF DATE: 10/01/03 FULL DESC:TOILET RAIL, EACH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 PER LIFETIME NH: N COPAY: $ 1.00 E0244 PAC: 170 MAX FEE: $ 38.01 EFF DATE: 10/01/03 FULL DESC:RAISED TOILET SEAT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: N COPAY: $ 2.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 26 E0245 PAC: 170 MAX FEE: $ 56.28 EFF DATE: 10/01/03 FULL DESC:TUB STOOL OR BENCH POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0245 RR PAC: 170 MAX FEE: $ 0.51 EFF DATE: 10/01/03 FULL DESC:TUB STOOL OR BENCH POS: 11 12 99 PROV TYPES: VALID 24 26 35 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0246 PAC: 170 MAX FEE: $ 140.10 EFF DATE: 10/01/03 FULL DESC:TRANSFER TUB RAIL ATTACHMENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0247 PAC: 170 MAX FEE: $ 153.26 EFF DATE: 01/01/04 FULL DESC:TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING POS: 11 12 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0247 RR PAC: 170 MAX FEE: $ 0.86 EFF DATE: 01/01/04 FULL DESC:TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING POS: 11 12 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0248 PAC: 170 MAX FEE: $ 228.00 EFF DATE: 05/01/05 FULL DESC:TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING POS: 11 12 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 27 E0248 RR PAC: 170 MAX FEE: $ 0.86 EFF DATE: 01/01/04 FULL DESC:TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING POS: 11 12 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + COMMODES ------------------------------------------------------------------------------- E0160 PAC: 170 MAX FEE: $ 31.96 EFF DATE: 07/01/02 FULL DESC:SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: N COPAY: $ 2.00 E0161 PAC: 170 MAX FEE: $ 31.96 EFF DATE: 07/01/02 FULL DESC:SITZ TYPE BATH OR EQUIPMENT, PORTABLE, USED WITH OR WITHOUT COMMODE, WITH FAUCET ATTACHMENTS POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: N COPAY: $ 2.00 E0162 PAC: 170 MAX FEE: $ 11.98 EFF DATE: 07/01/02 FULL DESC:SITZ BATH CHAIR POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 4 YEARS NH: N COPAY: $ 1.00 E0163 PAC: 170 MAX FEE: $ 76.93 EFF DATE: 10/01/03 FULL DESC:COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 28 E0163 RR PAC: 170 MAX FEE: $ 0.66 EFF DATE: 07/01/02 FULL DESC:COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED ARMS POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0167 PAC: 170 MAX FEE: $ 14.81 EFF DATE: 07/01/02 FULL DESC:PAIL OR PAN FOR USE WITH COMMODE CHAIR, REPLACEMENT ONLY POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: N COPAY: $ 1.00 E0168 PAC: 170 MAX FEE: $ 145.96 EFF DATE: 10/01/03 FULL DESC:COMMODE CHAIR, EXTRA WIDE AND/OR HEAVY DUTY, STATIONARY OR MOBILE, WITH OR WITHOUT ARMS, ANY TYPE, EACH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0175 PAC: 170 MAX FEE: $ 81.44 EFF DATE: 07/01/02 FULL DESC:FOOT REST, FOR USE WITH COMMODE CHAIR, EACH POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 ------------------------------------------------------------------------------- + DECUBITUS CARE EQUIPMENT ------------------------------------------------------------------------------- A4640 PAC: 170 MAX FEE: $ 39.47 EFF DATE: 07/01/02 FULL DESC:REPLACEMENT PAD FOR USE WITH MEDICALLY NECESSARY ALTERNATING PRESSURE PAD OWNED BY THE PATIENT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: N COPAY: $ 2.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 29 E0181 PAC: 170 MAX FEE: $ 241.68 EFF DATE: 07/01/02 FULL DESC:POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 YEAR NH: N COPAY: $ 3.00 E0181 RR PAC: 170 MAX FEE: $ 1.40 EFF DATE: 07/01/02 FULL DESC:POWERED PRESSURE REDUCING MATTRESS OVERLAY/PAD, ALTERNATING, WITH PUMP, INCLUDES HEAVY DUTY POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0182 PAC: 170 MAX FEE: $ 197.33 EFF DATE: 07/01/02 FULL DESC:PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 YEAR NH: N COPAY: $ 3.00 E0182 RR PAC: 170 MAX FEE: $ 1.05 EFF DATE: 07/01/02 FULL DESC:PUMP FOR ALTERNATING PRESSURE PAD, FOR REPLACEMENT ONLY POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0184 PAC: 170 MAX FEE: $ 182.73 EFF DATE: 07/01/02 FULL DESC:DRY PRESSURE MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: N COPAY: $ 3.00 E0185 PAC: 170 MAX FEE: $ 239.65 EFF DATE: 07/01/02 FULL DESC:GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 30 E0185 RR PAC: 170 MAX FEE: $ 1.28 EFF DATE: 07/01/02 FULL DESC:GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: NH: N COPAY: $ 0.00 E0186 PAC: 170 MAX FEE: $ 399.43 EFF DATE: 07/01/02 FULL DESC:AIR PRESSURE MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: N COPAY: $ 3.00 E0186 RR PAC: 170 MAX FEE: $ 2.51 EFF DATE: 07/01/02 FULL DESC:AIR PRESSURE MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0187 PAC: 170 MAX FEE: $ 378.46 EFF DATE: 07/01/02 FULL DESC:WATER PRESSURE MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: N COPAY: $ 3.00 E0187 RR PAC: 170 MAX FEE: $ 2.51 EFF DATE: 07/01/02 FULL DESC:WATER PRESSURE MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0188 PAC: 170 MAX FEE: $ 25.95 EFF DATE: 07/01/02 FULL DESC:SYNTHETIC SHEEPSKIN PAD POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 2.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 31 E0189 PAC: 170 MAX FEE: $ 49.93 EFF DATE: 07/01/02 FULL DESC:LAMBSWOOL SHEEPSKIN PAD, ANY SIZE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 2.00 E0193 RR PAC: 170 MAX FEE: $ 19.61 EFF DATE: 07/01/02 FULL DESC:POWERED AIR FLOATATION BED (LOW AIR LOSS THERAPY) POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 E0194 RR PAC: 170 MAX FEE: $ 31.12 EFF DATE: 07/01/02 FULL DESC:AIR FLUIDIZED BED POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 E0196 PAC: 170 MAX FEE: $ 249.64 EFF DATE: 07/01/02 FULL DESC:GEL PRESSURE MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: N COPAY: $ 3.00 E0196 RR PAC: 170 MAX FEE: $ 1.75 EFF DATE: 07/01/02 FULL DESC:GEL PRESSURE MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0197 PAC: 170 MAX FEE: $ 178.75 EFF DATE: 07/01/02 FULL DESC:AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 32 E0197 RR PAC: 170 MAX FEE: $ 1.23 EFF DATE: 07/01/02 FULL DESC:AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0198 PAC: 170 MAX FEE: $ 189.74 EFF DATE: 07/01/02 FULL DESC:WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: N COPAY: $ 3.00 E0199 PAC: 170 MAX FEE: $ 44.02 EFF DATE: 07/01/02 FULL DESC:DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: N COPAY: $ 2.00 E0277 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/92 FULL DESC:POWERED PRESSURE-REDUCING AIR MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 1.00 E0277 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/92 FULL DESC:POWERED PRESSURE-REDUCING AIR MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: NH: N COPAY: $ 0.00 E0372 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 02/01/99 FULL DESC:POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 33 E0372 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 02/01/99 FULL DESC:POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + HEAT AND COLD APPLICATION ------------------------------------------------------------------------------- E0200 PAC: 170 MAX FEE: $ 67.14 EFF DATE: 07/01/02 FULL DESC:HEAT LAMP, WITHOUT STAND (TABLE MODEL), INCLUDES BULB, OR INFRARED ELEMENT POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0202 RR PAC: 170 MAX FEE: $ 11.29 EFF DATE: 10/01/03 FULL DESC:PHOTOTHERAPY (BILIRUBIN) LIGHT WITH PHOTOMETER POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 30 LIFE EXP: NH: N COPAY: $ 0.00 E0203 PAC: 170 MAX FEE: $ 400.00 EFF DATE: 10/01/03 FULL DESC:THERAPEUTIC LIGHTBOX, MINIMUM 10,000 LUX, TABLE TOP MODEL POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: Y COPAY: $ 3.00 E0205 PAC: 170 MAX FEE: $ 65.82 EFF DATE: 07/01/02 FULL DESC:HEAT LAMP, WITH STAND, INCLUDES BULB, OR INFRARED ELEMENT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 34 E0215 PAC: 170 MAX FEE: $ 24.96 EFF DATE: 07/01/02 FULL DESC:ELECTRIC HEAT PAD; MOIST POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 1.00 ------------------------------------------------------------------------------- + HOSPITAL BEDS ------------------------------------------------------------------------------- E0250 PAC: 170 MAX FEE: $ 634.34 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED, FIXED-HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0250 RR PAC: 170 MAX FEE: $ 2.02 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED, FIXED-HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0251 PAC: 170 MAX FEE: $ 535.67 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED, FIXED-HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0251 RR PAC: 170 MAX FEE: $ 2.02 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED, FIXED-HEIGHT, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 35 E0255 PAC: 170 MAX FEE: $ 937.31 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS; WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0255 RR PAC: 170 MAX FEE: $ 3.08 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS; WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0256 PAC: 170 MAX FEE: $ 803.47 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS; WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0256 RR PAC: 170 MAX FEE: $ 3.08 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED, VARIABLE HEIGHT, HI-LO, WITH ANY TYPE SIDE RAILS; WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0260 PAC: 170 MAX FEE: $ 1259.92 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS; WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0260 RR PAC: 170 MAX FEE: $ 3.92 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS; WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 36 E0261 PAC: 170 MAX FEE: $ 1126.70 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0261 RR PAC: 170 MAX FEE: $ 3.92 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0265 PAC: 170 MAX FEE: $ 1829.12 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS; WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0265 RR PAC: 170 MAX FEE: $ 4.18 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS; WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0266 PAC: 170 MAX FEE: $ 1730.46 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; TOTAL ELECTRIC (HEAD, FOOT, AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS; WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0266 RR PAC: 170 MAX FEE: $ 4.18 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; TOTAL ELECTRIC (HEAD, FOOT, AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS; WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 37 E0270 PAC: 170 MAX FEE: $ 1198.29 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; INSTITUTIONAL TYPE INCLUDES: OSCILLATING, CIRCULATING AND STRYKER FRAME, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0270 RR PAC: 170 MAX FEE: $ 4.12 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; INSTITUTIONAL TYPE INCLUDES: OSCILLATING, CIRCULATING AND STYKER FRAME, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0290 PAC: 170 MAX FEE: $ 417.28 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; FIXED-HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0290 RR PAC: 170 MAX FEE: $ 2.02 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; FIXED-HEIGHT, WITHOUT SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0291 PAC: 170 MAX FEE: $ 284.07 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; FIXED-HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0291 RR PAC: 170 MAX FEE: $ 2.02 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; FIXED-HEIGHT, WITHOUT SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 38 E0292 PAC: 170 MAX FEE: $ 818.94 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0292 RR PAC: 170 MAX FEE: $ 3.08 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0293 PAC: 170 MAX FEE: $ 685.71 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0293 RR PAC: 170 MAX FEE: $ 3.08 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0294 PAC: 170 MAX FEE: $ 1126.70 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0294 RR PAC: 170 MAX FEE: $ 3.92 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 39 E0295 PAC: 170 MAX FEE: $ 993.51 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0295 RR PAC: 170 MAX FEE: $ 3.92 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; SEMI-ELECTRIC (HEAD AND FOOT ADJUSTMENT), WITHOUT SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0296 PAC: 170 MAX FEE: $ 1730.46 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS; WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0296 RR PAC: 170 MAX FEE: $ 4.18 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS; WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0297 PAC: 170 MAX FEE: $ 1597.24 EFF DATE: 10/01/03 FULL DESC:HOSPITAL BED; TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS; WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0297 RR PAC: 170 MAX FEE: $ 4.18 EFF DATE: 07/01/02 FULL DESC:HOSPITAL BED; TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS; WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 40 E0301 PAC: 170 MAX FEE: $ 3230.91 EFF DATE: 01/01/04 FULL DESC:HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0301 RR PAC: 170 MAX FEE: $ 7.62 EFF DATE: 01/01/04 FULL DESC:HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0302 PAC: 170 MAX FEE: $ 5259.13 EFF DATE: 01/01/04 FULL DESC:HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0302 RR PAC: 170 MAX FEE: $ 12.13 EFF DATE: 01/01/04 FULL DESC:HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0303 PAC: 170 MAX FEE: $ 3430.91 EFF DATE: 01/01/04 FULL DESC:HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 41 E0303 RR PAC: 170 MAX FEE: $ 7.62 EFF DATE: 01/01/04 FULL DESC:HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0304 PAC: 170 MAX FEE: $ 5459.13 EFF DATE: 01/01/04 FULL DESC:HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 E0304 RR PAC: 170 MAX FEE: $ 12.13 EFF DATE: 01/01/04 FULL DESC:HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + MATTRESSES ------------------------------------------------------------------------------- E0271 PAC: 170 MAX FEE: $ 133.21 EFF DATE: 07/01/02 FULL DESC:MATTRESS; INNERSPRING POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 4 YEARS NH: N COPAY: $ 3.00 E0272 PAC: 170 MAX FEE: $ 11.79 EFF DATE: 07/01/02 FULL DESC:MATTRESS; FOAM RUBBER POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 4 YEARS NH: N COPAY: $ 1.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 42 ------------------------------------------------------------------------------- + BED ACCESSORIES ------------------------------------------------------------------------------- E0305 PAC: 170 MAX FEE: $ 109.52 EFF DATE: 07/01/02 FULL DESC:BED SIDE RAILS; HALF LENGTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0305 RR PAC: 170 MAX FEE: $ 0.88 EFF DATE: 07/01/02 FULL DESC:BED SIDE RAILS; HALF LENGTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0310 PAC: 170 MAX FEE: $ 118.39 EFF DATE: 07/01/02 FULL DESC:BED SIDE RAILS; FULL LENGTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0310 RR PAC: 170 MAX FEE: $ 0.88 EFF DATE: 07/01/02 FULL DESC:BED SIDE RAILS; FULL LENGTH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 S8270 PAC: 170 MAX FEE: $ 60.16 EFF DATE: 07/01/05 FULL DESC:ENURESIS ALARM, USING AUDITORY BUZZER AND/OR VIBRATION DEVICE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 43 ------------------------------------------------------------------------------- + BED PANS/URINALS ------------------------------------------------------------------------------- E0275 PAC: 170 MAX FEE: $ 8.20 EFF DATE: 07/01/02 FULL DESC:BED PAN; STANDARD, METAL OR PLASTIC POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: N COPAY: $ 0.50 E0276 PAC: 170 MAX FEE: $ 8.20 EFF DATE: 07/01/02 FULL DESC:BED PAN; FRACTURE, METAL OR PLASTIC POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: N COPAY: $ 0.50 E0325 PAC: 170 MAX FEE: $ 9.23 EFF DATE: 07/01/02 FULL DESC:URINAL; MALE, JUG/TYPE, ANY MATERIAL POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 2 PER YEAR NH: N COPAY: $ 0.50 E0326 PAC: 170 MAX FEE: $ 6.89 EFF DATE: 07/01/02 FULL DESC:URINAL; FEMALE, JUG/TYPE, ANY MATERIAL POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 1 YEAR NH: N COPAY: $ 0.50 ------------------------------------------------------------------------------- + MONITORING EQUIPMENT ------------------------------------------------------------------------------- E0607 PAC: 170 MAX FEE: $ 59.92 EFF DATE: 07/01/02 FULL DESC:HOME BLOOD GLUCOSE MONITOR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 44 E0619 PAC: 170 MAX FEE: $ 1890.69 EFF DATE: 10/01/03 FULL DESC:APNEA MONITOR, WITH RECORDING FEATURE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0619 RR PAC: 170 MAX FEE: $ 5.06 EFF DATE: 10/01/03 FULL DESC:APNEA MONITOR, WITH RECORDING FEATURE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 90 LIFE EXP: NH: N COPAY: $ 0.00 E2100 PAC: 170 MAX FEE: $ 494.50 EFF DATE: 10/01/03 FULL DESC:BLOOD GLUCOSE MONITOR WITH INTEGRATED VOICE SYNTHESIZER POS: 11 12 PROV TYPES: VALID 24 26 44 45 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E2101 PAC: 170 MAX FEE: $ 142.50 EFF DATE: 10/01/03 FULL DESC:BLOOD GLUCOSE MONITOR WITH INTEGRATED LANCING/BLOOD SAMPLE POS: 11 12 PROV TYPES: VALID 24 26 44 45 48 54 58 BI: N PA REQ: Y LIFE EXP: 4 YEARS NH: N COPAY: $ 3.00 ------------------------------------------------------------------------------- + COMMUNICATION DEVICES ------------------------------------------------------------------------------- E2500 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, LESS THAN OR EQUAL TO 8 MINUTES RECORDING TIME POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 45 E2500 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, LESS THAN OR EQUAL TO 8 MINUTES RECORDING TIME POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 E2502 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 8 MINUTES BUT LESS THAN OR EQUAL TO 20 MINUTES RECORDING TIME POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 E2502 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 8 MINUTES BUT LESS THAN OR EQUAL TO 20 MINUTES RECORDING TIME POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 E2504 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 20 MINUTES BUT LESS THAN OR EQUAL TO 40 MINUTES RECORDING TIME POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 E2504 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 20 MINUTES BUT LESS THAN OR EQUAL TO 40 MINUTES RECORDING TIME POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 46 E2506 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 40 MINUTES RECORDING TIME POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 E2506 RR PAC: 170 MAX FEE: $ 7.80 EFF DATE: 04/01/06 FULL DESC:SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 40 MINUTES RECORDING TIME POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: 60 LIFE EXP: NH: Y COPAY: $ 0.00 E2508 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING MESSAGE FORMULATION BY SPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICE POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 E2508 RR PAC: 170 MAX FEE: $ 9.00 EFF DATE: 04/01/06 FULL DESC:SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, REQUIRING MESSAGE FORMULATION BY SPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICE POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: 60 LIFE EXP: NH: Y COPAY: $ 0.00 E2510 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OF MESSAGE FORMULATION AND MULTIPLE METHODS OF DEVICE ACCESS POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 E2510 RR PAC: 170 MAX FEE: $ 18.00 EFF DATE: 04/01/06 FULL DESC:SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OF MESSAGE FORMULATION AND MULTIPLE METHODS OF DEVICE ACCESS POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: 60 LIFE EXP: NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 47 E2511 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITAL ASSISTANT POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 E2511 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITAL ASSISTANT POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 E2512 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 E2512 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 E2599 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:ACCESSORY FOR SPEECH GENERATING DEVICE, NOT OTHERWISE CLASSIFIED POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 3.00 E2599 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 01/01/04 FULL DESC:ACCESSORY FOR SPEECH GENERATING DEVICE, NOT OTHERWISE CLASSIFIED POS: 11 12 31 32 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 48 L8500 PAC: 170 MAX FEE: $ 530.81 EFF DATE: 12/01/05 FULL DESC:ARTIFICIAL LARYNX, ANY TYPE POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: N LIFE EXP: NH: Y COPAY: $ 3.00 L8501 PAC: 170 MAX FEE: $ 84.00 EFF DATE: 03/01/04 FULL DESC:TRACHEOSTOMY SPEAKING VALVE (EACH) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: N LIFE EXP: NH: Y COPAY: $ 3.00 V5336 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 02/23/98 FULL DESC:REPAIR/MODIFICATION OF AUGMENTATIVE COMMUNICATIVE SYSTEM OR DEVICE (EXCLUDES ADAPTIVE HEARING AID) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: $ 300.00 LIFE EXP: NH: Y COPAY: $ 0.00 ------------------------------------------------------------------------------- + PATIENT LIFTS ------------------------------------------------------------------------------- E0621 PAC: 170 MAX FEE: $ 44.55 EFF DATE: 10/01/03 FULL DESC:SLING OR SEAT, PATIENT LIFT, CANVAS OR NYLON POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 2 YEARS NH: N COPAY: $ 2.00 E0630 PAC: 170 MAX FEE: $ 891.02 EFF DATE: 10/01/03 FULL DESC:PATIENT LIFT; HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S) POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 49 E0630 RR PAC: 170 MAX FEE: $ 2.08 EFF DATE: 10/01/03 FULL DESC:PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S) POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0635 PAC: 170 MAX FEE: $ 1868.32 EFF DATE: 10/01/03 FULL DESC:PATIENT LIFT; ELECTRIC WITH SEAT OR SLING POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0635 RR PAC: 170 MAX FEE: $ 4.09 EFF DATE: 10/01/03 FULL DESC:PATIENT LIFT; ELECTRIC WITH SEAT OR SLING POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0638 PAC: 170 MAX FEE: $ 1300.75 EFF DATE: 01/01/04 FULL DESC:STANDING FRAME SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS POS: 12 PROV TYPES: VALID 24 44 48 54 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0638 RR PAC: 170 MAX FEE: $ 2.89 EFF DATE: 01/01/04 FULL DESC:STANDING FRAME SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS POS: 12 PROV TYPES: VALID 24 44 48 54 BI: N PA REQ: Y LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 50 ------------------------------------------------------------------------------- + PNEUMATIC EQUIPMENT ------------------------------------------------------------------------------- E0650 PAC: 170 MAX FEE: $ 672.05 EFF DATE: 07/01/02 FULL DESC:PNEUMATIC COMPRESSOR; NON-SEGMENTAL HOME MODEL POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0650 RR PAC: 170 MAX FEE: $ 1.78 EFF DATE: 07/01/02 FULL DESC:PNEUMATIC COMPRESSOR; NON-SEGMENTAL HOME MODEL POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0651 PAC: 170 MAX FEE: $ 895.04 EFF DATE: 07/01/02 FULL DESC:PNEUMATIC COMPRESSOR; SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSURE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E0651 RR PAC: 170 MAX FEE: $ 3.04 EFF DATE: 07/01/02 FULL DESC:PNEUMATIC COMPRESSOR; SEGMENTAL HOME MODEL WITHOUT CALIBRATED GRADIENT PRESSURE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0652 PAC: 170 MAX FEE: $ 948.66 EFF DATE: 07/01/02 FULL DESC:PNEUMATIC COMPRESSOR; SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 51 E0652 RR PAC: 170 MAX FEE: $ 4.98 EFF DATE: 07/01/02 FULL DESC:PNEUMATIC COMPRESSOR; SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0655 PAC: 170 MAX FEE: $ 120.88 EFF DATE: 07/01/02 FULL DESC:NON-SEGMENTAL PNEUMATIC APPLICANCE FOR USE WITH PNEUMATIC COMPRESSOR; HALF ARM POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0655 RR PAC: 170 MAX FEE: $ 0.42 EFF DATE: 07/01/01 FULL DESC:NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; HALF ARM POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0660 PAC: 170 MAX FEE: $ 120.88 EFF DATE: 07/01/02 FULL DESC:NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; FULL LEG POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0660 RR PAC: 170 MAX FEE: $ 0.42 EFF DATE: 07/01/01 FULL DESC:NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; FULL LEG POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0665 PAC: 170 MAX FEE: $ 120.88 EFF DATE: 07/01/02 FULL DESC:NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; FULL ARM POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 52 E0665 RR PAC: 170 MAX FEE: $ 0.42 EFF DATE: 07/01/01 FULL DESC:NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; FULL ARM POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0666 PAC: 170 MAX FEE: $ 120.88 EFF DATE: 07/01/02 FULL DESC:NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; HALF LEG POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0666 RR PAC: 170 MAX FEE: $ 0.42 EFF DATE: 07/01/01 FULL DESC:NON-SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; HALF LEG POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0667 PAC: 170 MAX FEE: $ 375.46 EFF DATE: 07/01/02 FULL DESC:SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; FULL LEG POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0667 RR PAC: 170 MAX FEE: $ 1.89 EFF DATE: 07/01/02 FULL DESC:SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; FULL LEG POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0668 PAC: 170 MAX FEE: $ 363.49 EFF DATE: 07/01/02 FULL DESC:SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; FULL ARM POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 53 E0668 RR PAC: 170 MAX FEE: $ 1.79 EFF DATE: 07/01/02 FULL DESC:SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR; FULL ARM POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0669 PAC: 170 MAX FEE: $ 349.51 EFF DATE: 07/01/02 FULL DESC:SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH SEGMENTAL PNEUMATIC COMPRESSOR, HALF LEG POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0669 RR PAC: 170 MAX FEE: $ 3.51 EFF DATE: 07/01/02 FULL DESC:SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH SEGMENTAL PNEUMATIC COMPRESSOR, HALF LEG POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 65 BI: Y PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + ELECTROTHERAPY MODALITIES ------------------------------------------------------------------------------- A4630 PAC: 170 MAX FEE: $ 49.93 EFF DATE: 07/01/02 FULL DESC:REPLACEMENT BATTERIES, MEDICALLY NECESSARY, TRANSCUTANEOUS ELECTRIC AL STIMULATOR, OWNED BY PATIENT POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 2 PER 3 MONTHS NH: N COPAY: $ 2.00 E0720 PAC: 170 MAX FEE: $ 358.22 EFF DATE: 07/01/02 FULL DESC:TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 54 E0720 RR PAC: 170 MAX FEE: $ 1.19 EFF DATE: 07/01/02 FULL DESC:TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED STIMULATION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0730 PAC: 170 MAX FEE: $ 361.12 EFF DATE: 07/01/02 FULL DESC:TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0730 RR PAC: 170 MAX FEE: $ 1.20 EFF DATE: 07/01/02 FULL DESC:TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0731 PAC: 170 MAX FEE: $ 74.90 EFF DATE: 07/01/02 FULL DESC:FORM FITTING CONDUCTIVE GARMENT FOR DELIVERY OF TENS OR NMES (W/CONDUCTIVE FIBERS SEPARATED FROM THE PATIENT'S SKIN BY LAYERS OF FABRIC) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: Y COPAY: $ 3.00 E0744 PAC: 170 MAX FEE: $ 568.79 EFF DATE: 07/01/02 FULL DESC:NEUROMUSCULAR STIMULATOR; FOR SCOLIOSIS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: Y COPAY: $ 3.00 E0744 RR PAC: 170 MAX FEE: $ 2.00 EFF DATE: 07/01/02 FULL DESC:NEUROMUSCULAR STIMULATOR; FOR SCOLIOSIS POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 55 E0745 PAC: 170 MAX FEE: $ 580.36 EFF DATE: 07/01/02 FULL DESC:NEUROMUSCULAR STIMULATOR; ELECTRONICS SHOCK UNIT POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0745 RR PAC: 170 MAX FEE: $ 3.07 EFF DATE: 07/01/02 FULL DESC:NEUROMUSCULAR STIMULATOR; ELECTRONICS SHOCK UNIT POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0746 PAC: 170 MAX FEE: $ 699.00 EFF DATE: 07/01/02 FULL DESC:ELECTROMYOGRAPHY (EMG), BIOFEEDBACK DEVICE POS: 11 12 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0746 RR PAC: 170 MAX FEE: $ 14.98 EFF DATE: 07/01/02 FULL DESC:ELECTROMYOGRAPHY (EMG), BIOFEEDBACK DEVICE POS: 11 12 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0747 PAC: 170 MAX FEE: $ 2384.63 EFF DATE: 07/01/02 FULL DESC:OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASISVE, OTHER THAN SPINAL APPLICATIONS POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 E0748 PAC: 170 MAX FEE: $ 2995.74 EFF DATE: 07/01/02 FULL DESC:OSTEOGENESIS STIMULATOR, ELECTRICAL, NONINVASIVE, SPINAL APPLICATION POS: 11 12 PROV TYPES: VALID 24 54 BI: N PA REQ: Y LIFE EXP: NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 56 E0760 PAC: 170 MAX FEE: $ 2527.22 EFF DATE: 01/01/04 FULL DESC:OSTOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON-INVASIVE POS: 11 12 31 32 PROV TYPES: VALID 54 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 L8621 PAC: 170 MAX FEE: $ 1.02 EFF DATE: 10/01/07 FULL DESC: POS: 11 12 22 24 31 32 99 PROV TYPES: VALID 19 20 21 22 36 37 54 BI: N PA REQ: N LIFE EXP: 33 PER MONTH NH: Y COPAY: $ 0.50 L8622 PAC: 170 MAX FEE: $ 1.02 EFF DATE: 10/01/07 FULL DESC: POS: 11 12 22 24 31 32 99 PROV TYPES: VALID 19 20 21 22 36 37 54 BI: N PA REQ: N LIFE EXP: 33 PER MONTH NH: Y COPAY: $ 0.50 L8623 PAC: 170 MAX FEE: $ 53.00 EFF DATE: 10/01/07 FULL DESC:LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, OTHER THAN EAR LEVEL, REPLACEMENT, EACH POS: 11 12 22 24 31 32 99 PROV TYPES: VALID 24 26 36 37 44 48 54 BI: N PA REQ: N LIFE EXP: 2 PER YEAR NH: N COPAY: $ 2.00 L8624 PAC: 170 MAX FEE: $ 122.00 EFF DATE: 10/01/07 FULL DESC:LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, EAR LEVEL, REPLACEMENT, EACH POS: 11 12 22 24 31 32 99 PROV TYPES: VALID 24 26 36 37 44 48 54 BI: N PA REQ: N LIFE EXP: 2 PER YEAR NH: N COPAY: $ 3.00 L8680 PAC: 170 MAX FEE: $ 3948.00 EFF DATE: 01/01/06 FULL DESC:IMPLANTABLE NEUROSTIMULATOR ELECTRODE, EACH POS: 22 24 PROV TYPES: VALID 54 BI: N PA REQ: N LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 57 L8685 PAC: 170 MAX FEE: $11999.00 EFF DATE: 01/01/06 FULL DESC:IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, RECHARGEABLE, INCLUDES EXTENSION POS: 22 24 PROV TYPES: VALID 54 BI: N PA REQ: N LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 L8686 PAC: 170 MAX FEE: $11999.00 EFF DATE: 01/01/06 FULL DESC:IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, SINGLE ARRAY, NON- RECHARGEABLE, INCLUDES EXTENSION POS: 22 24 PROV TYPES: VALID 54 BI: N PA REQ: N LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 L8687 PAC: 170 MAX FEE: $11999.00 EFF DATE: 01/01/06 FULL DESC:IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, RECHARGEABLE, INCLUDES EXTENSION POS: 22 24 PROV TYPES: VALID 54 BI: N PA REQ: N LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 L8688 PAC: 170 MAX FEE: $11999.00 EFF DATE: 01/01/06 FULL DESC:IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR, DUAL ARRAY, NON- RECHARGEABLE, INCLUDES EXTENSION POS: 22 24 PROV TYPES: VALID 54 BI: N PA REQ: N LIFE EXP: 10 YEARS NH: N COPAY: $ 3.00 ------------------------------------------------------------------------------- + PUMPS ------------------------------------------------------------------------------- A4210 PAC: 170 MAX FEE: $ 487.69 EFF DATE: 07/01/02 FULL DESC:NEEDLE-FREE INJECTION DEVICE, EACH POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 3 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 58 B9002 PAC: 170 MAX FEE: $ 1121.97 EFF DATE: 10/01/03 FULL DESC:ENTERAL NUTRITION INFUSION PUMP; WITH ALARM POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 B9002 RR PAC: 170 MAX FEE: $ 2.49 EFF DATE: 01/01/04 FULL DESC:ENTERAL NUTRITION INFUSION PUMP WITH ALARM POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 180 LIFE EXP: NH: N COPAY: $ 0.00 B9004 PAC: 170 MAX FEE: $ 2261.35 EFF DATE: 01/01/04 FULL DESC:PARENTERAL NUTRITION INFUSION PUMP, PORTABLE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: Y COPAY: $ 3.00 B9004 RR PAC: 170 MAX FEE: $ 4.97 EFF DATE: 01/01/04 FULL DESC:PARENTERAL NUTRITION INFUSION PUMP; PORTABLE POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 180 LIFE EXP: NH: Y COPAY: $ 0.00 B9006 PAC: 170 MAX FEE: $ 2261.35 EFF DATE: 01/01/04 FULL DESC:PARENTERAL NUTRITION INFUSION PUMP, STATIONARY POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: Y COPAY: $ 3.00 B9006 RR PAC: 170 MAX FEE: $ 4.97 EFF DATE: 01/01/04 FULL DESC:PARENTERAL NUTRITION INFUSION PUMP, STATIONARY POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 180 LIFE EXP: NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 59 E0602 PAC: 170 MAX FEE: $ 55.00 EFF DATE: 10/01/02 FULL DESC:BREAST PUMP, MANUAL, ANY TYPE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0603 PAC: 170 MAX FEE: $ 155.00 EFF DATE: 10/01/02 FULL DESC:BREAST PUMP, ELECTRIC (AC AND/OR DC), ANY TYPE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0604 RR PAC: 170 MAX FEE: $ 2.06 EFF DATE: 10/01/02 FULL DESC:BREAST PUMP, HOSPITAL GRADE, ELECTIRC (AC AND/OR DC), ANY TYPE POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0776 PAC: 170 MAX FEE: $ 139.51 EFF DATE: 07/01/02 FULL DESC:I.V. POLE (NOT FOR USE WITH PORTABLE PUMPS) POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: N LIFE EXP: 8 YEARS NH: N COPAY: $ 3.00 E0776 RR PAC: 170 MAX FEE: $ 0.61 EFF DATE: 07/01/02 FULL DESC:I.V. POLE (NOT FOR USE WITH PORTABLE PUMPS) POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0781 PAC: 170 MAX FEE: $ 3426.15 EFF DATE: 01/01/04 FULL DESC:AMBULATORY INFUSION PUMP, SINGLE OR MUTLIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT, WORN BY PATIENT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 60 E0781 RR PAC: 170 MAX FEE: $ 7.53 EFF DATE: 01/01/04 FULL DESC:AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT, WORN BY PATIENT POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 180 LIFE EXP: NH: Y COPAY: $ 0.00 E0784 PAC: 170 MAX FEE: $ 5054.94 EFF DATE: 10/01/03 FULL DESC:EXTERNAL, AMBULATORY INFUSION PUMP, INSULIN POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: Y COPAY: $ 3.00 E0784 RR PAC: 170 MAX FEE: $ 8.41 EFF DATE: 07/01/02 FULL DESC:EXTERNAL AMBULATORY INFUSION PUMP, INSULIN POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: Y COPAY: $ 0.00 E0791 PAC: 170 MAX FEE: $ 3594.50 EFF DATE: 01/01/04 FULL DESC:PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTICHANNEL POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: Y COPAY: $ 3.00 E0791 RR PAC: 170 MAX FEE: $ 7.90 EFF DATE: 01/01/04 FULL DESC:PARENTERAL INFUSION PUMP, STATIONARY, SINGLE OR MULTICHANNEL POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 180 LIFE EXP: NH: Y COPAY: $ 0.00 E1520 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 08/01/93 FULL DESC:HEPARIN INFUSION PUMP FOR DIALYSIS POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 2 YEARS NH: Y COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 61 E1520 RR PAC: 170 MAX FEE: $ 4.52 EFF DATE: 07/01/02 FULL DESC:HEPARIN INFUSION PUMP FOR DIALYSIS POS: 11 12 31 32 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: Y COPAY: $ 0.00 E2000 PAC: 170 MAX FEE: $ 955.77 EFF DATE: 10/01/03 FULL DESC:GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 E2000 RR PAC: 170 MAX FEE: $ 1.73 EFF DATE: 10/01/03 FULL DESC:GASTRIC SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E2402 RR PAC: 170 MAX FEE: $ 59.31 EFF DATE: 07/01/05 FULL DESC:NEGATIVE PRESSURE WOUND THERAPY ELECTRICALPUMP, STATIONARY OR PORTABLE POS: 11 12 PROV TYPES: VALID 24 44 48 54 BI: N PA REQ: Y LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + TRACTION AND RELATED EQUIPMENT - CERVICAL ------------------------------------------------------------------------------- E0840 PAC: 170 MAX FEE: $ 29.64 EFF DATE: 07/01/02 FULL DESC:TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 2.00 E0840 RR PAC: 170 MAX FEE: $ 0.23 EFF DATE: 07/01/01 FULL DESC:TRACTION FRAME, ATTACHED TO HEADBOARD, CERVICAL TRACTION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 62 E0850 PAC: 170 MAX FEE: $ 88.85 EFF DATE: 07/01/02 FULL DESC:TRACTION STAND, FREE STANDING, CERVICAL TRACTION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0850 RR PAC: 170 MAX FEE: $ 0.51 EFF DATE: 07/01/02 FULL DESC:TRACTION STAND, FREE STANDING, CERVICAL TRACTION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + TRACTION EQUIPMENT - OVERDOOR ------------------------------------------------------------------------------- E0860 PAC: 170 MAX FEE: $ 27.68 EFF DATE: 07/01/02 FULL DESC:TRACTION EQUIPMENT, OVERDOOR, CERVICAL POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 2.00 E0860 RR PAC: 170 MAX FEE: $ 0.23 EFF DATE: 07/01/01 FULL DESC:TRACTION EQUIPMENT, OVERDOOR, CERVICAL POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + TRACTION EQUIPMENT - EXTREMITY ------------------------------------------------------------------------------- E0870 PAC: 170 MAX FEE: $ 56.28 EFF DATE: 07/01/02 FULL DESC:TRACTION FRAME, ATTACHED TO FOOTBOARD, EXTREMITY TRACTION (E.G., BUCK'S) POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 63 E0870 RR PAC: 170 MAX FEE: $ 0.51 EFF DATE: 07/01/02 FULL DESC:TRACTION FRAME, ATTACHED TO FOOTBOARD, EXTREMITY TRACTION (E.G., BUCK'S) POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0880 PAC: 170 MAX FEE: $ 63.69 EFF DATE: 07/01/02 FULL DESC:TRACTION STAND, FREE STANDING, EXTREMITY TRACTION, (E.G., BUCK'S) POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0880 RR PAC: 170 MAX FEE: $ 0.51 EFF DATE: 07/01/02 FULL DESC:TRACTION STAND, FREE STANDING, EXTREMITY TRACTION, (E.G., BUCK'S) POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + TRACTION EQUIPMENT - PELVIC ------------------------------------------------------------------------------- E0890 PAC: 170 MAX FEE: $ 72.04 EFF DATE: 07/01/02 FULL DESC:TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0890 RR PAC: 170 MAX FEE: $ 0.51 EFF DATE: 07/01/02 FULL DESC:TRACTION FRAME, ATTACHED TO FOOTBOARD, PELVIC TRACTION POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0900 PAC: 170 MAX FEE: $ 56.28 EFF DATE: 07/01/02 FULL DESC:TRACTION STAND, FREE STANDING, PELVIC TRACTION (E.G., BUCK'S) POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 64 E0900 RR PAC: 170 MAX FEE: $ 1.05 EFF DATE: 07/01/02 FULL DESC:TRACTION STAND, FREE STANDING, PELVIC TRACTION (E.G., BUCK'S) POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + TRAPEZE EQUIPMENT, FRACTURE FRAME AND OTHER ORTHOPEDIC DEVICES ------------------------------------------------------------------------------- E0910 PAC: 170 MAX FEE: $ 113.48 EFF DATE: 07/01/02 FULL DESC:TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0910 RR PAC: 170 MAX FEE: $ 1.00 EFF DATE: 07/01/02 FULL DESC:TRAPEZE BARS, A/K/A PATIENT HELPER, ATTACHED TO BED, WITH GRAB BAR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0911 PAC: 170 MAX FEE: $ 113.48 EFF DATE: 01/01/06 FULL DESC:TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, ATTACHED TO BED, WITH GRAB BAR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0911 RR PAC: 170 MAX FEE: $ 1.00 EFF DATE: 01/01/06 FULL DESC:TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNGS, ATTACHED TO BED, WITH GRAB BAR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 65 E0912 PAC: 170 MAX FEE: $ 895.00 EFF DATE: 01/01/06 FULL DESC:TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREE STANDING, COMPLETE WITH GRAB BAR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0912 RR PAC: 170 MAX FEE: $ 3.34 EFF DATE: 01/01/06 FULL DESC:TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREE STANDING, COMPLETE WITH GRAB BAR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0920 PAC: 170 MAX FEE: $ 368.96 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; ATTACHED TO BED, INCLUDES WEIGHTS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0920 RR PAC: 170 MAX FEE: $ 1.05 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; ATTACHED TO BED, INCLUDES WEIGHTS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0930 PAC: 170 MAX FEE: $ 998.58 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; FREE STANDING, INCLUDES WEIGHTS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0930 RR PAC: 170 MAX FEE: $ 4.98 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; FREE STANDING, INCLUDES WEIGHTS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 66 E0935 RR PAC: 170 MAX FEE: $ 14.98 EFF DATE: 07/01/02 FULL DESC:CONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE ON KNEE ONLY POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 E0940 PAC: 170 MAX FEE: $ 290.17 EFF DATE: 07/01/02 FULL DESC:TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0940 RR PAC: 170 MAX FEE: $ 0.51 EFF DATE: 07/01/02 FULL DESC:TRAPEZE BAR, FREE STANDING, COMPLETE WITH GRAB BAR POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0941 PAC: 170 MAX FEE: $ 591.96 EFF DATE: 07/01/02 FULL DESC:GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0941 RR PAC: 170 MAX FEE: $ 2.08 EFF DATE: 07/01/02 FULL DESC:GRAVITY ASSISTED TRACTION DEVICE, ANY TYPE POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0942 PAC: 170 MAX FEE: $ 16.45 EFF DATE: 07/01/02 FULL DESC:CERVICAL HEAD HARNESS/HALTER POS: 11 12 99 PROV TYPES: VALID 24 26 34 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 1.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 67 E0944 PAC: 170 MAX FEE: $ 34.94 EFF DATE: 07/01/02 FULL DESC:PELVIC BELT/HARNESS/BOOT POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 2.00 E0945 PAC: 170 MAX FEE: $ 13.99 EFF DATE: 07/01/02 FULL DESC:EXTREMITY BELT/HARNESS POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 1.00 E0946 PAC: 170 MAX FEE: $ 399.43 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; DUAL WITH CROSS BARS, ATTACHED TO BED, (E.G., BALKEN, 4 POSTER) POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0946 RR PAC: 170 MAX FEE: $ 2.00 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; DUAL WITH CROSS BARS, ATTACHED TO BED, (E.G., BALKEN, 4 POSTER) POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 E0947 PAC: 170 MAX FEE: $ 444.03 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; ATTACHMENTS FOR COMPLEX PELVIC TRACTION POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0947 RR PAC: 170 MAX FEE: $ 1.10 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; ATTACHMENTS FOR COMPLEX PELVIC TRACTION POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 68 E0948 PAC: 170 MAX FEE: $ 444.03 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; ATTACHMENTS FOR COMPLEX CERVICAL TRACTION POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 1 PER LIFETIME NH: N COPAY: $ 3.00 E0948 RR PAC: 170 MAX FEE: $ 1.10 EFF DATE: 07/01/02 FULL DESC:FRACTURE FRAME; ATTACHMENTS FOR COMPLEX CERVICAL TRACTION POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + ADAPTIVE EQUIPMENT ------------------------------------------------------------------------------- A9281 PAC: 170 MAX FEE: $ 18.50 EFF DATE: 01/01/06 FULL DESC:REACHING/GRABBING DEVICE, ANY TYPE, ANY LENGTH, EACH POS: 12 PROV TYPES: VALID 24 26 44 48 54 BI: N PA REQ: N LIFE EXP: 3 YEARS NH: N COPAY: $ 1.00 A9900 PAC: 170 MAX FEE: $ 0.01 EFF DATE: 09/01/05 FULL DESC:MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE POS: 12 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 BI: N PA REQ: N LIFE EXP: NH: Y COPAY: $ 0.50 ------------------------------------------------------------------------------- + POSITIONING EQUIPMENT ------------------------------------------------------------------------------- T5001 PAC: 170 MAX FEE: $ 649.08 EFF DATE: 01/01/04 FULL DESC:POSITIONING SEAT FOR PERSONS WITH SPECIAL ORTHOPEDIC NEEDS, FOR USE IN VEHICLES POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: Y LIFE EXP: 5 YEARS NH: N COPAY: $ 3.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 69 T5001 RR PAC: 170 MAX FEE: $ 1.48 EFF DATE: 01/01/04 FULL DESC:POSITIONING SEAT FOR PERSONS WITH SPECIAL ORTHOPEDIC NEEDS, FOR USE IN VEHICLES POS: 11 12 PROV TYPES: VALID 24 26 44 48 54 58 BI: N PA REQ: 60 LIFE EXP: NH: N COPAY: $ 0.00 ------------------------------------------------------------------------------- + MISCELLANEOUS DME AND REPAIR ------------------------------------------------------------------------------- E1340 PAC: 170 MAX FEE: $ 10.84 EFF DATE: 07/01/02 FULL DESC:REPAIR OR NONROUTINE SERVICE FOR DURABLE MEDICAL EQUIPMENT REQUIRING THE SKILL OF A TECHNICIAN; LABOR COMPONENT, PER 15 MINUTES POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 36 38 44 48 54 58 65 78 BI: N PA REQ: $ 84.01 LIFE EXP: NH: Y COPAY: $ 0.00 E1399 PAC: 11J MAX FEE: $ 0.00 EFF DATE: 10/01/03 FULL DESC:DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS (MUST SPECIFY COMPLETE DESCRIPTION OF DME) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 78 79 80 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 1.00 E1399 RR PAC: 11J MAX FEE: $ 0.00 EFF DATE: 10/01/03 FULL DESC:DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS (MUST SPECIFY COMPLETE DESCRIPTION OF DME) POS: 11 12 31 32 99 PROV TYPES: VALID 24 26 34 35 38 44 48 54 58 65 78 79 80 BI: N PA REQ: Y LIFE EXP: NH: Y COPAY: $ 0.00 REPORT JOB: SWIJMPQD DME INDEX/MAFS DATE: 041008 REPORT NAME: HMPRDM54 PAGE: 70 ********************