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The following sections of the Fidelis Care authorization grids have been updated effective November 1, 2024.
The following codes have been added to the Medicaid DME Authorization Grid:
A4543
Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month
A4544
Electrode for external lower extremity nerve stimulator for restless legs syndrome
A4545
Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month
C8000
Support device, extravascular, for arteriovenous fistula (implantable)
E0469
Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device
E0683
Non-pneumatic, non-sequential, peristaltic wave compression pump
E0715
Intravaginal device intended to strengthen pelvic floor muscles during kegel exercises
E0716
Supplies and accessories for intravaginal device intended to strengthen pelvic floor muscles during kegel exercises
E0721
Transcutaneous electrical nerve stimulatory, stimulates nerves in the auricular region
E0737
Transcutaneous tibial nerve stimulator, controlled by phone application
E0743
External lower extremity nerve stimulator for restless legs syndrome, each
E0767
Intrabuccal, systemic delivery of amplitude-modulated, radiofrequency electromagnetic field device, for cancer treatment, includes all accessories
E2513
Accessory for speech generating device, electromyographic sensor
E3200
Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only
L1006
Scoliosis orthosis, sagittal-coronal control provided by a rigid lateral frame, extends from axilla to trochanter, includes all accessory pads, straps and interface, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L1653
Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, off the shelf
L1821
Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, off the shelf
L8720
External lower extremity sensory prosthesis, cutaneous stimulation of mechanoreceptors proximal to the ankle, per leg
L8721
Receptor sole for use with L8720, replacement, each
Visit: Authorization Grids
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