L33318 · Knee Orthoses
Version 63. CMS effective date 01/25/2026. CMS updated 12/04/2025. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. None
HCPCS · Medicare DME
A9270 Medicare coverage
NON-COVERED ITEM OR SERVICE
Long description on the CMS LCD code table, this read.
Data read from the CMS Coverage API on 2026-10-13. The LCD version is the current final DME MAC LCD on that read. Text below is quoted from those CMS documents. Nothing here is a coverage rule Verzi wrote.
Coverage, in CMS's words
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33318 version 63, effective 01/25/2026. CMS LCD L33318.
Local coverage indication
Refer to the NONMEDICAL NECESSITY COVERAGE AND PAYMENT RULES section of the Policy Article for information about coverage for appliances that achieve their effect through positioning of the tongue (A9270). A prefabricated oral appliance (E0485) will be denied as not reasonable and necessary. There is insufficient evidence to show that these items are effective therapy for OSA. As used in this policy, treating practitioner refers to a licensed MD, DO, nurse practitioner, clinical nurse specialist, or physician's assistant working within their scope of practice. The term treating practitioner does not include a dentist (DDS or DMD). Apnea is defined as the cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds associated with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation. The apnea-hypopnea index (AHI) is defined as the average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the AHI. Sleep time can only be measured in a Type I (facility-based polysomnogram) or Type II sleep study (see descriptions below). The respiratory disturbance index (RDI) is defined as the average number of apneas plus hypopneas per hour of recording without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the RDI. The RDI is reported in Type III, Type IV, and Other home sleep studies. If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate the AHI or RDI (respectively) must be at least the number of events that would have been required in a 2-hour period (i.e., must reach > 30 events without symptoms or > 10 events with symptoms).
Excerpt from LCD L33611 version 25, effective 08/08/2021. CMS LCD L33611.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33735 version 19, effective 01/01/2020. CMS LCD L33735.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33733 version 19, effective 01/01/2020. CMS LCD L33733.
National coverage indication, NCD 280.2
A white cane for use by a blind person is more an identifying and self-help device rather than an item which makes a meaningful contribution in the treatment of an illness or injury.
Excerpt from NCD 280.2 version 1. CMS NCD 280.2.
What NCD 280.3 says the item is
A. General The Centers for Medicare & Medicaid Services (CMS) addresses numerous items that it terms “mobility assistive equipment” (MAE) and includes within that category canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters. This list, however, is not exhaustive. Medicare beneficiaries may require mobility assistance for a variety of reasons and for varying durations because the etiology of the disability may be due to a congenital cause, injury, or disease. Thus, some beneficiaries experiencing temporary disability may need mobility assistance on a short-term basis, while in contrast, those living with chronic conditions or enduring disabilities will require mobility assistance on a permanent basis. Medicare beneficiaries who depend upon mobility assistance are found in varied living situations.
National coverage indication, NCD 280.3
B. Nationally Covered Indications Effective May 5, 2005, CMS finds that the evidence is adequate to determine that MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home. Determination of the presence of a mobility deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate MAE to correct the mobility deficit. Clinical Criteria for MAE Coverage The beneficiary, the beneficiary’s family or other caregiver, or a clinician, will usually initiate the discussion and consideration of MAE use. Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity to restore the beneficiary’s ability to participate in MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. These questions correspond to the numbered decision points on the accompanying flow chart.
Excerpt from NCD 280.3 version 2. CMS NCD 280.3.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33790 version 20, effective 01/01/2020. CMS LCD L33790.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33791 version 18, effective 10/01/2026. CMS LCD L33791.
What NCD 280.3 says the item is
A. General The Centers for Medicare & Medicaid Services (CMS) addresses numerous items that it terms “mobility assistive equipment” (MAE) and includes within that category canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters. This list, however, is not exhaustive. Medicare beneficiaries may require mobility assistance for a variety of reasons and for varying durations because the etiology of the disability may be due to a congenital cause, injury, or disease. Thus, some beneficiaries experiencing temporary disability may need mobility assistance on a short-term basis, while in contrast, those living with chronic conditions or enduring disabilities will require mobility assistance on a permanent basis. Medicare beneficiaries who depend upon mobility assistance are found in varied living situations.
National coverage indication, NCD 280.3
B. Nationally Covered Indications Effective May 5, 2005, CMS finds that the evidence is adequate to determine that MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home. Determination of the presence of a mobility deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate MAE to correct the mobility deficit. Clinical Criteria for MAE Coverage The beneficiary, the beneficiary’s family or other caregiver, or a clinician, will usually initiate the discussion and consideration of MAE use. Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity to restore the beneficiary’s ability to participate in MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. These questions correspond to the numbered decision points on the accompanying flow chart.
Excerpt from NCD 280.3 version 2. CMS NCD 280.3.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33792 version 43, effective 10/01/2025. CMS LCD L33792.
What NCD 280.3 says the item is
A. General The Centers for Medicare & Medicaid Services (CMS) addresses numerous items that it terms “mobility assistive equipment” (MAE) and includes within that category canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters. This list, however, is not exhaustive. Medicare beneficiaries may require mobility assistance for a variety of reasons and for varying durations because the etiology of the disability may be due to a congenital cause, injury, or disease. Thus, some beneficiaries experiencing temporary disability may need mobility assistance on a short-term basis, while in contrast, those living with chronic conditions or enduring disabilities will require mobility assistance on a permanent basis. Medicare beneficiaries who depend upon mobility assistance are found in varied living situations.
National coverage indication, NCD 280.3
B. Nationally Covered Indications Effective May 5, 2005, CMS finds that the evidence is adequate to determine that MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home. Determination of the presence of a mobility deficit will be made by an algorithmic process, Clinical Criteria for MAE Coverage, to provide the appropriate MAE to correct the mobility deficit. Clinical Criteria for MAE Coverage The beneficiary, the beneficiary’s family or other caregiver, or a clinician, will usually initiate the discussion and consideration of MAE use. Sequential consideration of the questions below provides clinical guidance for the coverage of equipment of appropriate type and complexity to restore the beneficiary’s ability to participate in MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. These questions correspond to the numbered decision points on the accompanying flow chart.
Excerpt from NCD 280.3 version 2. CMS NCD 280.3.
What NCD 280.16 says the item is
A. General Power seat elevation equipment used with a power wheelchair raises and lowers users while they remain in the seated position. This equipment uses an electromechanical lift system to provide varying amounts of vertical seat to floor height. It does not change the seated angles or the seat’s angle relative to the ground. Complex rehabilitative power-driven wheelchairs are defined in 42 CFR §414.202.
National coverage indication, NCD 280.16
B. Nationally Covered Indications Effective for services performed on or after May 16, 2023, power seat elevation equipment is reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs, when the following conditions are met: 1. The individual has undergone a specialty evaluation that confirms the individual’s ability to safely operate the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations; and, 2. At least one of the following apply: The individual performs weight bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or, The individual requires a non-weight bearing transfer (e.g.
Excerpt from NCD 280.16 version 1. CMS NCD 280.16.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33794 version 176, effective 10/01/2026. CMS LCD L33794.
What NCD 280.14 says the item is
A. General Infusion pumps are medical devices used to deliver solutions containing parenteral drugs under pressure at a regulated flow rate.
National coverage indication, NCD 280.14
B. Nationally Covered Indications The following indications for treatment using infusion pumps are covered under Medicare: 1. External Infusion Pumps a. Iron Poisoning (Effective for Services Performed On or After September 26, 1984) When used in the administration of deferoxamine for the treatment of acute iron poisoning and iron overload, only external infusion pumps are covered. b. Thromboembolic Disease (Effective for Services Performed On or After September 26, 1984) When used in the administration of heparin for the treatment of thromboembolic disease and/or pulmonary embolism, only external infusion pumps used in an institutional setting are covered. c. Chemotherapy for Liver Cancer (Effective for Services Performed On or After January 29, 1985) The external chemotherapy infusion pump is covered when used in the treatment of primary hepatocellular carcinoma or colorectal cancer where this disease is unresectable; OR, where the patient refuses surgical excision of the tumor. d.
Excerpt from NCD 280.14 version 2. CMS NCD 280.14.
Local coverage indication
Covered supplies for reasonable and necessary non-routine irrigation of a catheter include either an irrigation tray (A4320) or an irrigation syringe (A4322), and sterile water/saline (A4217). When syringes, trays, sterile saline, or water are used for routine irrigation, they will be denied as not reasonable and necessary. Irrigation solutions containing antibiotics and chemotherapeutic agents (A9270) will be denied as non-covered. Irrigating solutions such as acetic acid or hydrogen peroxide, which are used for the treatment or prevention of urinary obstruction (A4321), will be denied as not reasonable and necessary. CONTINUOUS IRRIGATION OF INDWELLING CATHETERS Supplies for continuous irrigation of a catheter are covered if there is a history of obstruction of the catheter and the patency of the catheter cannot be maintained by intermittent irrigation in conjunction with reasonable and necessary catheter changes. Continuous irrigation as a primary preventative measure (i.e., no history of obstruction) will be denied as not reasonable and necessary. Documentation must substantiate the medical necessity of catheter irrigation and in particular continuous irrigation as opposed to intermittent irrigation. The records must also indicate the rate of solution administration and the duration of need. This documentation must be available upon request.
Excerpt from LCD L33803 version 61, effective 04/01/2026. CMS LCD L33803.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33826 version 22, effective 01/01/2026. CMS LCD L33826.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33830 version 22, effective 05/01/2021. CMS LCD L33830.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33828 version 27, effective 01/01/2024. CMS LCD L33828.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L33831 version 48, effective 01/01/2024. CMS LCD L33831.
What NCD 270.4 says the item is
An accepted procedure for healing decubitus ulcers is to remove dead tissue from the lesions and to keep them clean to promote the growth of new tissue. This may be accomplished by hydrotherapy (whirlpool) treatments.
National coverage indication, NCD 270.4
Hydrotherapy (whirlpool) treatment for decubitus ulcers is a covered service under Medicare for patients when treatment is reasonable and necessary. Some other methods of treating decubitus ulcers, the safety and effectiveness of which have not been established, are not covered under the Medicare program. Some examples of these types of treatments are: ultraviolet light, low intensity direct current, topical application of oxygen, and topical dressings with Balsam of Peru in castor oil.
Excerpt from NCD 270.4 version 1. CMS NCD 270.4.
National coverage indication, NCD 270.5
Porcine (pig) skin dressings are covered, if reasonable and necessary for the individual patient as an occlusive dressing for burns, donor sites of a homograft, and decubiti and other ulcers. Gradient pressure dressings are Jobst elasticized heavy duty dressings used to reduce hypertrophic scarring and joint contractures following burn injury. They are covered when used for that purpose.
Excerpt from NCD 270.5 version 1. CMS NCD 270.5.
Local coverage indication
Benefit Category and other statutory requirements are discussed in the related Policy Article NONMEDICAL NECESSITY AND COVERAGE RULES section. Refer to the Policy article for information on these criteria. In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
Excerpt from LCD L36267 version 44, effective 04/01/2026. CMS LCD L36267.
What NCD 230.15 says the item is
An electrical continence aid is a device consisting of a plastic plug, molded into the shape of the patient's anal canal, which contains two implanted electrodes that are connected by a wire to a small portable generator. An electrical current is produced which stimulates the anal musculature to cause a contraction sufficient to hold the plug in while allowing the patient to ambulate without incontinence.
National coverage indication, NCD 230.15
Not Covered Electrical continence aids are in the experimental stage of development and there is no valid scientific documentation of their effectiveness and safety. Therefore, they are not covered under Medicare since they cannot be considered to be reasonable and necessary for the treatment of an illness or injury or to improve the functioning of a malformed body member as required by §1862(a)(1) of the Act.
Excerpt from NCD 230.15 version 1. CMS NCD 230.15.
Local coverage indication
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Excerpt from LCD L38955 version 24, effective 01/01/2024. CMS LCD L38955.
Governing LCD
L33611 · Oral Appliances for Obstructive Sleep Apnea
Version 25. CMS effective date 08/08/2021. CMS updated 06/18/2021. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
L33735 · Cold Therapy
Version 19. CMS effective date 01/01/2020. CMS updated 02/13/2020. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. None
L33733 · Canes and Crutches
Version 19. CMS effective date 01/01/2020. CMS updated 02/13/2020. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.2, 280.3
L33790 · Spinal Orthoses: TLSO and LSO
Version 20. CMS effective date 01/01/2020. CMS updated 02/28/2020. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. None
L33791 · Walkers
Version 18. CMS effective date 10/01/2026. CMS updated 09/25/2026. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.1, 280.3
L33792 · Wheelchair Options/Accessories
Version 43. CMS effective date 10/01/2025. CMS updated 10/23/2025. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. Pub. 100-03 (Medicare National Coverage Determinations Manual), Chapter 1, Sections 280.1, 280.3, 280.16
L33794 · External Infusion Pumps
Version 176. CMS effective date 10/01/2026. CMS updated 09/29/2026. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Sections 280.1 and 280.14
L33803 · Urological Supplies
Version 61. CMS effective date 04/01/2026. CMS updated 04/02/2026. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. None
L33826 · Oral Anticancer Drugs
Version 22. CMS effective date 01/01/2026. CMS updated 12/31/2025. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. CMS Benefits Policy Manual (IOM 100-02), Chapter 15, Section 50 - Drugs and Biologicals Social Security Act, Sec. 1861(s)(Q)
L33830 · Pressure Reducing Support Surfaces - Group 1
Version 22. CMS effective date 05/01/2021. CMS updated 03/12/2021. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. CMS Pub. 100-03, (Medicare National Coverage Determinations Manual), Chapter 1, Section 280.1
L33828 · Ostomy Supplies
Version 27. CMS effective date 01/01/2024. CMS updated 12/07/2023. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. None
L33831 · Surgical Dressings
Version 48. CMS effective date 01/01/2024. CMS updated 02/08/2024. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. CMS Manual System, Pub. 100-02, Benefit Policy Manual, Chapter 15, Section 100, 100-03, National Coverage Determinations Manual, Chapter 1, Sections 270.4 & 270.5
L36267 · Bowel Management Devices
Version 44. CMS effective date 04/01/2026. CMS updated 04/08/2026. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
CMS coverage policy citation on the LCD. CMS Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Sections 230.15 and 280.1
L38955 · Enteral Nutrition
Version 24. CMS effective date 01/01/2024. CMS updated 12/07/2023. Contractors on the CMS report: CGS Administrators (DME MAC) and Noridian Healthcare Solutions (DME MAC).
Governing NCD
NCD 280.1 · Durable Medical Equipment Reference List
Current version on the CMS national report: 4. Effective date 06/09/2025. Benefit category: Durable Medical Equipment. The LCD lists related NCD version 1. The excerpt on this page, when present, is version 4.
NCD 280.2 · White Cane for Use by a Blind Person
Current version on the CMS national report: 1. Effective date This is a longstanding national coverage determination. The effective date of this version has not been posted.. Benefit category: Durable Medical Equipment.
NCD 280.3 · Mobility Assistive Equipment (MAE)
Current version on the CMS national report: 2. Effective date 05/05/2005. Benefit category: Durable Medical Equipment. The LCD lists related NCD version 1. The excerpt on this page, when present, is version 2.
NCD 280.16 · Seat Elevation Equipment (Power Operated) on Power Wheelchairs
Current version on the CMS national report: 1. Effective date 05/16/2023. Benefit category: Durable Medical Equipment.
NCD 280.14 · Infusion Pumps
Current version on the CMS national report: 2. Effective date 12/17/2004. Benefit category: Durable Medical Equipment.
NCD 270.4 · Treatment of Decubitus Ulcers
Current version on the CMS national report: 1. Effective date This is a longstanding national coverage determination. The effective date of this version has not been posted.. Benefit category: Physicians' Services.
NCD 270.5 · Porcine Skin and Gradient Pressure Dressings
Current version on the CMS national report: 1. Effective date This is a longstanding national coverage determination. The effective date of this version has not been posted.. Benefit category: Surgical Dressings.
NCD 230.15 · Electrical Continence Aid
Current version on the CMS national report: 1. Effective date This is a longstanding national coverage determination. The effective date of this version has not been posted.. Benefit category: Prosthetic Devices.
Documentation requirements
From A52465
For a knee orthosis with adjustable knee joints or a prefabricated Swedish type knee orthosis (L1832, L1833, L1850), the medical records must include documentation of the beneficiary’s physical examination of the affected knee(s), including all of the following: The joint laxity test(s) performed; and, A description of the exam findings that support objective joint laxity. For a knee orthosis with single or double upright, adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment (L1843, L1844, L1845, L1846, L1851, L1852) for the management of an ambulatory beneficiary with knee instability, the medical records must include documentation of all of the following: The beneficiary’s ambulatory status; and, A physical examination of the affected knee(s), including all of the following: The joint laxity test(s) performed; and, A description of the exam findings that support objective joint laxity.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52512
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. Treating practitioners shall document the in-person clinical evaluation in a detailed narrative note in their charts in the format that they use for other entries. The report would commonly document pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation. History Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches Duration of symptoms Validated sleep hygiene inventory such as the Epworth Sleepiness Scale (see
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52460
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52459
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52500
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. Based on Social Security Act §1834(h)(5), for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by the treating practitioner. When providing orthoses suppliers must: Provide the product that is specified by the treating practitioner Be sure that the treating practitioner's medical record justifies the need for the type of product (i.e.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From L33791
Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement. Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52504
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. SPECIALTY EVALUATION: The specialty evaluation provides detailed information explaining why each option and accessory – e.g., power tilt and/or recline seating systems, or gear reduction drive wheel – is needed to address the beneficiary’s mobility limitation. There must be a written report of this evaluation available on request. The PT, OT, or practitioner who performs the specialty evaluation may have no financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, the PT, OT, or practitioner working in the inpatient or outpatient hospital setting may perform the specialty evaluation.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52507
Coverage of an external infusion pump for the administration of continuous subcutaneous insulin as outlined in the related LCD’s “Coverage Indications, Limitations, and/or Medical” section under criteria IV. C. and D. requires a frequency of glucose self-testing an average of at least 4 times per day. A beneficiary using a continuous glucose monitor (CGM) is inherently testing more than the 4 times per day glucose monitoring requirement. Documentation of the use of a CGM device in the beneficiary’s medical records would meet the testing requirement in the External Infusion Pump LCD. In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. For parenteral inotropic drugs, the cardiologist with training in the management of advanced heart failure who performs the initial evaluation does not need to be the prescriber for the parenteral inotropic drug.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52521
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. When the prescribing practitioner is also the supplier, and is permitted to furnish specific items of DMEPOS, a separate order is not required; however, the medical record must still contain all of the required order elements. For intermittent catheterization using a sterile intermittent catheter kit (A4297, A4353), documentation in the medical records of a diagnosis of spinal cord injury (SCI) is sufficient to establish the beneficiary is immunocompromised. CONTINUED MEDICAL NEED For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered, therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52479
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. The ICD-10 diagnosis code describing the condition for which the drug is used must be included on each claim. Claims for codes J8498 or J8597 must identify the name of the drug, the manufacturer, and the dosage strength of each tablet/suppository/etc. Only quantities of these drugs which meet the coverage criteria listed in the Policy Article may be billed using these codes. The claim must also indicate which oral anticancer drug is being used and the prescribed frequency of administration of the anticancer drug. This information must be entered in the narrative field of an electronic claim.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52489
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. RELATED CLINICAL INFORMATION A beneficiary needing a pressure reducing support surface should have a care plan which has been established by the beneficiary's treating practitioner or home care nurse, which is documented in the beneficiary's medical records, and which generally should include the following: Education of the beneficiary and caregiver on the prevention and/or management of pressure ulcers Regular assessment by a nurse, treating practitioner , or other licensed healthcare practitioner Appropriate turning and positioning Appropriate wound care (for a stage 2, 3 or 4 ulcer) Appropriate management of moisture/incontinence Nutritional assessment and intervention consistent with the overall plan of care
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A52487
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. For quantities of supplies that exceed the usual maximum amount, there must be information in the medical record that explains the need for the increased amount. This information must be available upon request. Claims for tape and adhesive (A4450, A4452, A5120) that are billed without an AU modifier or another modifier indicating coverage under a different policy will be rejected as missing information. CONTINUED MEDICAL NEED For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered, therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. Once initial medical need is established, ongoing need for ostomy supplies is assumed to be met.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A54563
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. A new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased. A new order is required every 3 months for each dressing being used. When the prescribing practitioner is also the supplier, and is permitted to furnish specific items of DMEPOS, a separate order is not required; however, the medical record must still contain all of the required order elements. For initial wound evaluations, the treating practitioner’s medical record, nursing home, or home care nursing records must specify: The type of qualifying wound (see above); and, Information regarding the location, number, and size of qualifying wounds being treated with a dressing; and, Whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A54516
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
From A58833
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD. Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below. The supplier must enter a diagnosis code corresponding to the beneficiary's diagnosis on each claim. The beneficiary’s medical record must contain sufficient documentation of the beneficiary’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the beneficiary’s diagnosis and other pertinent information including, but not limited to, duration of the beneficiary’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. Information describing the medical necessity for enteral nutrition must be available upon request.
From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs
GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific
Denial language in the policy
- If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary. Source: L33318
- If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Source: L33318
- In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary. Source: L33318
- All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary. Source: L33318
- Irrigation solutions containing antibiotics and chemotherapeutic agents (A9270) will be denied as non-covered. Source: L33803
Get the signed answer via API
The signed answer is the receipt for this code on a date of service: the rule that was in force, with a hash you can replay. The call needs an API key. The source archive and as-of resolution are public.
curl -H "X-API-Key: $VERZI_API_KEY" \
"https://api.verzi.health/v1/rules/warrant?hcpcs=A9270&as_of=2024-01-15&npi=1234567890&state=UT"Other codes on the same LCD
A4467K0672L1810L1812L1820L1821L1830L9900E0485A9273E0218A4635A4636E0100E0105E0110E0111E0112E0113E0114E0116E0117E0118L0450L0452L0454L0455L0456A9900E0130E0135E0140E0141E0143E0144E0147E0148E0149E0150K0015K0017E0705K0108E0776K0455A4221A4223K0552A4217A4331A4450A4452E0181E0182E0184E0185E0186E0187E0188E0189E0196E0197E0198E0199A4364E0275E0276
Questions about this code
Which LCD lists A9270?
The current DME MAC LCD L33318, Knee Orthoses, version 63, effective 01/25/2026.
Which National Coverage Determination applies to A9270?
NCD 280.1, Durable Medical Equipment Reference List, version 4, is the current national document related from the LCD.
What denial language does CMS publish for A9270?
If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
How do I get a signed answer for A9270?
Request a free API key and call the signed-answer endpoint with the HCPCS code, a date of service, the supplier NPI, and a state. The response is a receipt for the published rule on that date, not a guarantee of payment.