AllWays Health Partners Prior Authorization Required For DME, Medical .

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsB4161Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includesfats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteralfeeding tube, 100 calories 1 unitUNIT specified to be used by DME Providers only. Home Infusion Providers: use1 UNIT 1 product unit.B4162Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism,includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administeredthrough an enteral feeding tube, 100 calories 1 unitUNIT specified to be used by DME Providers only. Home Infusion Providers: use1 UNIT 1 product unit.B4164Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml 1 unit)- home mixHome Infusion Providers ONLYB4168Parenteral nutrition solution; amino acid, 3.5%, (500 ml 1 unit) – home mixHome Infusion Providers ONLYB4172Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml 1 unit) – home mixHome Infusion Providers ONLYHCPCSCODESERVICE—LONG DESCRIPTIONCOMMENTB4176Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml 1 unit) – home mixHome Infusion Providers ONLYB4178Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml 1 unit)- home mixHome Infusion Providers ONLYB4180Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml 1 unit) –home mixHome Infusion Providers ONLYB4185Parenteral nutrition solution, per 10 grams lipidsHome Infusion Providers ONLYB4187Omegaven, 10 g lipidsB4189Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes,trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein premixHome Infusion Providers ONLYB4193Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes,trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein premixHome Infusion Providers ONLYAllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance Company5

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsB4197Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes,trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein premixHome Infusion Providers ONLYB4199Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes,trace elements and vitamins, including preparation, any strength, over 100 grams of protein premixHome Infusion Providers ONLYB4216Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) home mix perdayParenteral nutrition supply kit; premix, per dayParenteral nutrition supply kit; home mix, per dayParenteral nutrition administration kit, per dayParenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes,trace elements, and vitamins, including preparation, any strength, renal- amirosyn rf, nephramine, renamine - premixHome Infusion Providers ONLYB5100Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes,trace elements, and vitamins, including preparation, any strength, hepatic - freamine hbc,hepatamine - premixHome Infusion Providers ONLYHCPCSCODESERVICE—LONG DESCRIPTIONCOMMENTB5200Parenteral nutrition solution: compounded amino acid and carbohydrates with electrolytes,trace elements, and vitamins, including preparation, any strength, stress - branch chain aminoacids - premixHome Infusion Providers ONLYB9004Parenteral nutrition infusion pump, portableB9006Parenteral nutrition infusion pump, stationaryB9998Miscellaneous enteral feeding supplyD9947D9948D9949E0118E0170E0172E0193Custom sleep apnea appliance fabrication and placementAdjustment of custom sleep apnea applianceRepair of custom sleep apnea applianceCrutch substitute, lower leg platform, with or without wheels, eachCommode chair with integrated seat lift mechanism, electric, any typeSeat lift mechanism placed over or on top of toilet, any typePowered air flotation bed (low air loss therapy)B4220B4222B4224B5000AllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance CompanyHome Infusion Providers ONLYHome Infusion Providers ONLYHome Infusion Providers ONLYHome Infusion Providers ONLYRent to purchase fee6

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsE0194E0202E0203E0265Air fluidized bedPHOTOTHERAPY LIGHT WITH PHOTOMETERTherapeutic lightbox, minimum 10,000 lux, table top modelHospital bed, total electric (head, foot and height adjustments), with any type side rails, withmattressE0266Hospital bed, total electric (head, foot and height adjustments), with any type side rails,without mattressE0270Hospital bed, institutional type includes: oscillating, circulating and Stryker frame, withmattressE0277E0294Powered pressure-reducing air mattressHospital bed, semi-electric (head and foot adjustment), without side rails, with mattressE0296Hospital bed, total electric (head, foot and height adjustments). without side rails, withmattressE0297Hospital bed, total electric (head, foot and height adjustments), without side rails, withoutmattressE0300Pediatric crib, hospital grade, fully enclosed, with or without top enclosureSERVICE—LONG DESCRIPTIONHCPCSCODEE0301Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but lessthan or equal to 600 pounds, with any type side rails, without mattressE0302Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds,with any type side rails, without mattressE0303Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but lessthan or equal to 600 pounds, with any type side rails, with mattressE0304Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds,with any type side rails, with mattressE0316Safety enclosure frame/canopy for use with hospital bed, any typeAllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance CompanyRent to purchase feeNot Payable per MassHealthCOMMENT7

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsE0328Hospital bed, pediatric, manual, 360-degree side enclosures, top of headboard, footboard andside rails up to 24 inches above the spring, includes mattressE0329Hospital bed, pediatric, electric or semi-electric, 360-degree side enclosures, top ofheadboard, footboard and side rails up to 24 inches above the spring, includes mattressE0371Nonpowered advanced pressure reducing overlay for mattress, standard mattress length andwidthE0372Powered air overlay for mattress, standard mattress length and widthE0373Nonpowered advanced pressure reducing mattressE0462E0465Rocking bed with or without side railsHome ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) [new code,effective: 01/01/2016]PA is required for home ventilators as of 01/01/2016.Note: codes E0450, E0460, E0461, E0463 and E0464 were deleted 12/31/2015E0466Home ventilator, any type, used with invasive non-interface, (e.g., mask, chest shell) [newcode, effective: 01/01/2016]PA is required for home ventilators as of 01/01/2016.Note: codes E0450, E0460, E0461, E0463 and E0464 were deleted 12/31/2015E0467Home ventilator, multi-function respiratory device, also performs any or all of the additionalfunctions of oxygen concentration, drug nebulization, aspiration, and cough stimulation,includes all accessories, components and supplies for all functionsE0470Respiratory assist device, bi-level pressure capability, without backup rate feature, used withnoninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuouspositive airway pressure device)Sleep Management Solutions, LLC ONLY (a.k.a. Care Centrix)HCPCSCODESERVICE—LONG DESCRIPTIONCOMMENTE0471Respiratory assist device, bi-level pressure capability, with back-up rate feature, used withnoninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuouspositive airway pressure device)Sleep Management Solutions, LLC ONLY (a.k.a. Care Centrix)E0472Respiratory assist device, bi-level pressure capability, with backup rate feature, used withinvasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positiveairway pressure device)E0481Intrapulmonary percussive ventilation system and related accessoriesAllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance Company8

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsE0482Cough stimulating device, alternating positive and negative airway pressureE0483High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest),eachE0486Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustmentNot Payable per MassHealthE0561E0562E0565Humidifier, non-heated, used with positive airway pressure deviceHumidifier, heated, used with positive airway pressure deviceCompressor, air power source for equipment which is not self-contained, or cylinder drivenSleep Management Solutions, LLC ONLY (a.k.a. Care Centrix)Sleep Management Solutions, LLC ONLY (a.k.a. Care Centrix)E0601E0617E0635Continuous positive airway pressure (cpap) deviceExternal defibrillator with integrated electrocardiogram analysisPatient lift, electric with seat or slingSleep Management Solutions, LLC ONLY (a.k.a. Care Centrix)E0636Multipositional patient support system, with integrated lift, patient accessible controlsE0637Combination sit to stand frame/table system, any size including pediatric, with seat liftfeature, with or without wheelsE0639Patient lift, moveable from room to room with disassembly and reassembly, includes allcomponents/accessoriesE0640Patient lift, fixed system, includes all components/accessoriesE0641Standing frame/table system, multi-position (e.g. three-way stander), any size includingpediatric, with or without wheelsE0642Standing frame/table system, mobile (dynamic stander), any size including pediatricHCPCSCODESERVICE—LONG DESCRIPTIONE0691Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatmentarea 2 sq ft or lessUltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ftpanelUltraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 ftpanelUltraviolet multidirectional light therapy system in 6 ft cabinet, includes bulbs/lamps, timer,and eye protectionPneumatic compressor, segmental home model with calibrated gradient pressureE0692E0693E0694E0652AllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance CompanyCOMMENT9

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsE0675Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterialinsufficiency (unilateral or bilateral system)E0700Safety equipment, device or accessory, any typeE0710E0745Restraints, any type (body, chest, wrist or ankle)Neuromuscular stimulator, electronic shock unitE0747Osteogenesis stimulator, electrical, non-invasive, other than spinal applicationsE0748E0760E0781Osteogenesis stimulator, electrical, non-invasive, spinal applicationsOsteogenesis stimulator, low intensity ultrasound, non-invasiveE0783Infusion pump system, implantable, programmable (includes all components, e.g., pump,catheter, connectors, etc.)E0791E0983Parenteral infusion pump, stationary, single or multi-channelE0984Manual wheelchair accessory, power add-on to convert manual wheelchair to motorizedwheelchair, tiller controlE0986E0988Manual wheelchair accessory, push activated power assist, eachManual wheelchair accessory, lever-activated, wheel drive, pairE1002E1003Wheelchair accessory, power seating system, tilt onlyWheelchair accessory, power seating system, recline only, without shear reductionE1004Wheelchair accessory, power seating system, recline only, with mechanical shear reductionE1005Wheelchair accessory, power seatng system, recline only, with power shear reductionE1006Wheelchair accessory, power seating system, combination tilt and recline, without shearreductionSERVICE—LONG DESCRIPTIONHCPCSCODEE1007Ambulatory infusion pump, single or multiple channels, electric or battery operated, withadministrative equipment, worn by patientManual wheelchair accessory, power add-on to convert manual wheelchair to motorizedwheelchair, joystick controlCOMMENTWheelchair accessory, power seating system, combination tilt and recline, with mechanicalshear reductionAllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance Company10

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsE1008Wheelchair accessory, power seating system, combination tilt and recline, with power shearreductionE1010Wheelchair accessory, addition to power seating system, power leg elevation system,including leg rest, pairTrapeze Equipment, Fracture Frame & Other Orthopdic DevicesE1012E1030E1035Wheelchair accessory, ventilator tray, gimbaledE1036Multi-positional patient transfer system, extra-wide, with integrated seat, operated bycaregiver, patient weight capacity greater than 300 lbs.E1060Fully-reclining wheelchair, detachable arms, desk or full length, swing away detachableelevating leg restsE1087High strength lightweight wheelchair, fixed full length arms, swing away detachable elevatingleg restsE1088High strength lightweight wheelchair, detachable arms desk or full length, swing awaydetachable elevating leg restsE1089High strength lightweight wheelchair, fixed length arms, swing away detachable footrestE1090High strength lightweight wheelchair, detachable arms desk or full length, swing awaydetachable foot restsE1161E1195Manual adult size wheelchair, includes tilt in spaceHeavy duty wheelchair, fixed full length arms, swing away detachable elevating leg restsE1220Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) andjustificationE1229E1230Wheelchair, pediatric size, not otherwise specifiedPower operated vehicle (three or four-wheel nonhighway) specify brand name and modelnumberSERVICE—LONG DESCRIPTIONHCPCSCODEE1231E1232Multi-positional patient transfer system, with integrated seat, operated by care giver, patientweight capacity up to and including 300 lbs.COMMENTWheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating systemWheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating systemAllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance Company11

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsE1233Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating systemE1234Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating systemE1235E1236E1237E1238E1239Wheelchair, pediatric size, rigid, adjustable, with seating systemWheelchair, pediatric size, folding, adjustable, with seating systemWheelchair, pediatric size, rigid, adjustable, without seating systemWheelchair, pediatric size, folding, adjustable, without seating systemPower wheelchair, pediatric size, not otherwise specifiedE1399Durable medical equipment, miscellaneousE1802Dynamic adjustable forearm pronation/supination device, includes soft interface materialE1831Static progressive stretch toe device, extension and/or flexion, with or without range ofmotion adjustment, includes all components and accessoriesE1840Dynamic adjustable shoulder flexion / abduction / rotation device, includes soft interfacematerialE1841Static progressive stretch shoulder device, with or without range of motion adjustment,includes all components and accessoriesE2217E2227E2230E2291E2292Manual wheelchair accessory, foam filled caster tire, any size, eachManual wheelchair accessory, gear reduction drive wheel, eachManual wheelchair accessory, manual standing systemBack, planar, for pediatric size wheelchair including fixed attaching hardwareSeat, planar, for pediatric size wheelchair including fixed attaching hardwareE2293Back, contoured, for pediatric size wheelchair including fixed attaching hardwareE2294Seat, contoured, for pediatric size wheelchair including fixed attaching hardwareHCPCSCODESERVICE—LONG DESCRIPTIONE2300Wheelchair accessory, power seat elevation system, any typeE2301Wheelchair accessory, power standing system, any typeAllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance CompanyCOMMENT12

AllWays Health Partners Prior Authorization Required for DME, Medical Supplies,Oxygen Related Equipment, Orthotics, Prosthetics and Hearing AidsE2310Power wheelchair accessory, electronic connection between wheelchair controller and onepower seating system motor, including all related electronics, indicator feature, mechanicalfunction selection switch, and fixed mounting hardwareE2311Power wheelchair accessory, electronic connection between wheelchair controller and two ormore power seating system motors, including all related electronics, indicator feature,mechanical function selection switch, and fixed mounting hardwareE2312Power wheelchair accessory, hand or chin control interface, mini-proportional remotejoystick, proportional, including fixed mounting hardwareE2321Power wheelchair accessory, hand control interface, remote joystick, nonproportional,including all related electronics, mechanical stop switch, and fixed mounting hardwareE2322Power wheelchair accessory, hand control interface, multiple mechanical switches,nonproportional, including all related electronics, mechanical stop switch, and fixed mountinghardwareE2325Power wheelchair accessory, sip and puff interface, nonproportional, including all relatedelectronics, mechanical stop switch, and manual swing away mounting hardwareE2327Power wheelchair accessory, head control interface, mechanical, proportional, including allrelated electronics, mechanical direction change switch, and fixed mounting hardwareE2328Power wheelchair accessory, head control or extremity control interface, electronic,proportional, including all related electronics and fixed mounting hardwareHCPCSCODESERVICE—LONG DESCRIPTIONE2329Power wheelchair accessory, head control interface, contact switch mechanism,nonproportional, including all related electronics, mechanical stop switch, mechanical

AllWays Health Partners includes AllWays Health Partners, Inc., and AllWays Health Partners Insurance Company 1 The DME, Medical Supplies, Oxygen Supplies, Orthotics, Prosthetics and Hearing Aid services listed below require a prior authorization (PA) and need to be obtained from an AllWays Health Partners contracted provider or vendor.