I/C Individual Consideration** Prosthetics . - Maryland

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Prosthetics, Orthotics, and Disposable SuppliesMaryland Medicaid DMS/DME Program Approved List of ItemsI/C Individual consideration**PA Prepayment authorization requiredModifiers are used for equipment servicesJANUARY CELLANEOUS SUPPLIESA4206Syringe w/needle 1cc eachY/12mosA4207Syringe with needle, sterile 2 cc. EachY/12 mosA4208Syringe w/needle, 3ccY/12 mosA4209Syringe w/needle, 5cc or greaterY/12 mosA4210Needle free injection devic used for Narcan/NaloxoneY/12 mosA4212Non-coring needle or stylet w/ or w/out catheterY/12 mosA4213Syringe, sterile, 20 cc or greaterY/12 mosA4215Needle, sterile, any size, eachY/12 mosA4216Sterile Water, Saline and/or dextrose /flush, 10 MLY/12 mosA4217Sterile Water/Saline, 500 MLY/12 mosA4218Sterile saline or water, metered dose dispenser, 10 mlY/12 mosA4221Supplies for maint drug infusion cath, non-insulin, per wk (list drug separtely)Y/12 mosA4222Supplies for external drug infusion pmpY/12 mosA4223Infusion supplies not used w/external infusion pump, per cassette or bagY/12 mosA4224Supplies insulin infusion cath per wkY/12 mosA4225Supplies for ext insulin infusion pump, syringe cart, sterile, eaY/12 mosA4230Infusion set for external insulin pump, nonneedle cannula typeY/12 mosYA4231Infusion set for external insulin pump, needle typeY/12 mosYA4232Syringe w/needle for external insulin pump, sterile 3cc (cartridge)Y/12 mosA4245Alcohol Wipes, per boxY/12 mosA4246Betadine or PhisoHex solution, per pintY/12 mosA4247Betadine or Iodine Swabs or Wipes, per boxY/12 mosA4250Urine strips per 100Y/12 mosA4252Blood Ketone Test StripsY/12 mosYA4253Blood glucose/reagent stripsY/12 mosA4255Platforms for home blood glucose monitor, 50 per boxY/12 mosA4256Normal, low, and high calibrator solution/chipsY/12 mosA4258Lancet device eachY/12 mosA4259Lancets per boxY/12 mosA4280Brst prsths adhsv attchmntY/12 mosA4305Disposable Drug Delivery Sys, flow rate of 50 ml or per hr (elsm pmp)Y/12 mosA4306Disposable Drug Delivery Sys, flow rate of less than 50 mil per hourY/12 mosINCONTINENCE APPLIANCES AND CARE SUPPLIESA4310Y/12 mosInsertion tray w/o drainage bag and w/o catheter (accessories only)LimitsPriceEffectiveDateRental Price(RR)MaxPurchasePrice (NU)250 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo400 every 2 mo200 every 2 mo16 every 2 mo60 every 2 mo140 every 2 mo16 every 2 mo60 every 2 mo60 every 2 mo2 every 2 mo200 every 2 mo10 bx/200 per box10 per mo20 bx per mo2 bx per moI/C8 bx/100 every 2 mo2 bx/100 every 2 mo2 bx every 2 mo4 bx/200/ every 2 mo4 bx/200/ every 2 mo2bx/400/every 2 mo120 every 2 mo120 every 2 .701.701.144.8215.5721.7460 every 2 mo1/1/216.66

A4373A4375A4376Catheter w/o bag 2-way latexY/12 mosCatheter w/o bag 2-way siliconeY/12 mosCatheter w/bag 3-wayY/12 mosCath w/drainage 2-way latexY/12 mosCath w/drainage 2-way siliconeY/12 mosCath w/drainage 3-wayY/12 mosIrrigation trayY/12 mosIrrigation syringeY/12 mosMale external catheter w/integral collection chamber, any type, eachY/12 mosFem urinary collect dev cupY/12 mosFem urinary collect pouchY/12 mosStool collection pouchY/12 mosExternal drainage tubing for urinary leg bag or urostomy, eaY/12 mosLubricant, individual sterile packet, eachY/12 mosUrinary catheter anchoring device, adhesive skin attachment, eaY/12 mosUrinary catheter anchoring device, leg strap, eachY/12 mosIncontinence supply; miscellaneousY/12 mosIndwelling catheter latexY/12 mosIndwelling catheter specialY/12 mosCath indw foley 2-way siliconeY/12 mosCath indw foley3-wayY/12 mosMale external catheter, with or without adhesive, disposable, eachY/12 mosStraight tip urine catheterY/12 mosCoude tip urinary catheterY/12 mosIntermittent urinary catheter, with insertion suppliesY/12 mosCath insertion tray w/bagY/12 mosBladder irrigation tubingY/12 mosEXTERNAL URINARY SUPPLIESExt ureth clmp or compr dvcY/12 mosBedside drainage bagY/12 mosUrinary leg bagY/12 mosY/12 mosOstomy face plate, eaSolid skin barrierY/12 mosOstomy Clamp, any type, replacement onlyY/12 mosAdhesive, liquid, or equal, any type, per ounceY/12 mosOstomy Vent, any type, eachY/12 mosOstomy beltY/12 mosOstomy filterY/12 mosSkin barrier liquid per ozY/12 mosOstomy skin barrier, powder, per oz/Y/12 mosOstomy skin barrier, solid 4X4 or equivalent, standard wear, w/blt-in convY/12 mosOstomy skin barrier, w/flange (solid, flex or accord), w/blt-in convex, any sizeY/12 mosDrainabale plastic pch w fcplY/12 mosDrainage rubber pch w w fcplY/12 mosY60 every 2 mo60 every 2 mo60 every 2 mo60 every 2 mo60 every 2 mo60 every 2 mo60 every 2 mo50 every 2 mo60 every 2 mo60 every 2 mo60 every 2 mo20 every 2 mo30 every 2 mo300 every 2 mo2 every 2 mo60 every 2 moI/C60 every 2 mo60 every 2 mo20 every 2 mo60 every 2 mo140 every 2 mo400 every 2 mo400 every 2 mo400 every 2 mo2 every 2 mo60 every 2 .3418.061.871.695.986.519.488.3010 every 2 mo72 every 2 mo72 every 2 mo10 every 2 mo10 every 2 mo2 every 2 mo20 oz. every 2 mo2 every 2 mo2 per yr60 every 2 mo32 oz every 2 mo64 oz every 2 mo60 every 2 mo60 every 2 mo20 every 2 mo20 every 2 905.8315.9944.31

A4420A4421A4422A4423Drainable plastic pouch w/o fpDrainable rubber pch w/o fpUrinary plastic pouch w fcplUrinary plastic pouch w/o fpOstomy pouch, urinary, for use on faceplate, heavy plastic, eachUrinary hvy plstc pch w/o fpUrinary rubber pouch w/o fpOstomy faceplt/silicone ringOst skn barrier sld ext wearOst clsd pouch w att st barrDrainable pch w ex wear barrDrainable pch w st wear barrDrainable pch ex wear convexUrinary pouch w ex wear barrUrinary pouch w st wear barrUrine pch w ex wear bar convOstomy deodorant, w/wo lubricant, for use in ostomy pouch, per fluid ozOstomy pouch solid deodorant, per tabletOstomy belt with peristomal hernia supportIrrigation supply sleeveOstomy irrigation bagOstomy irrig cone/cath w brsOstomy irrigation setOstomy lubricant, per ounceOstomy ring eachOstomy Skin Barrier, non-pectin base, paste, per ounceOstomy Skin Barrier, pectin-based, paste, per ounceOstomy Skin Barrier, w/flange, w/built-in convexity, 4 X 4 or smallerOstomy Skin Barrier, w/flange, w/built-in convexity, larger than 4 X 4 inchesOstomy Skin Barrier, w/flange, w/out built-in convexity, 4X4 or smallerOstomy Skin Barrier, w/flange, w/out built-in convexity, lager than 4X4Ostomy Skin Barrier, solid 4x4 or equivalent, extended wear, w/convex, eachOstomy Pouch, Drainable, high output, for use on a barrier w/flange, w/o fltOstomy pouch, drnble, high output, w/flng (2 ppc system) w/filterOstomy Skin Barrier, w/flange, 4X4 inches or smallerOstomy skin barrier w/flng, w/o convex, larger than 4X4 inches, eachOstomy pch clsd w/barrier/filtrOstomy pch w/bar/bltinconv/flteOstomy pch clsd w/o bar w/filtrOstomy pch, clsd for bar w/flange/fltrOstomy pch clsd for bar w/lck/flngOstomy supply; miscellaneousOstomy absorbent material (sheet/pad/crystal pkg) for use on ostmy pchOstomy pch for bar w/lck flange/filtrY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY60 every 2 mo20 every 2 mo30 every 2 mo20 every 2 mo60 every 2 mo2 every 2 mo60 every 2 mo10 every 2 mo40 every 2 mo120 every 2 mo200 every 2 mo40 every 2 mo40 every 2 mo40 every 2 mo40 every 2 mo40 every 2 mo32 oz every 2 mo200 every 2 mo4 every 2 mo80 every 2 mo60 every 2 mo60 every 2 mo10 every 2 mo100 every 2 mo60 every 2 mo12 oz.every 2 mo12 oz. every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo60 every 2 moI/CPA over 300.00400 every 2 mo60 every 2 73

y pch drainble/ w/ bar & filterY/12 mosOstomy pch drainable for barrier w/non lk flng w/flter 2 pc sysY/12 mosOstomy pch drain; for bar w/lck flng 2 pc sysY/12 mosOstomy pch drain; for bar w/lck flng, w/fltr 2 pc sysY/12 mosOstomy pch, urinary, w/est wr bar attch, w/fct-typ tap w/valv 1 pcY/12 mosOstomy pch, urinary, w/bar attch, w/blt-in-convx, w/fct-typ tap w/vlv 1 pcY/12 mosOstomy pch, urinary, w/ext wr bar attch w/blt-in convx, w/fct-typ tap 1 pcY/12 mosOstomy pch urinary; w/bar attch, w/fct-type tap w/vlv 1 pcY/12 mosOstomy pch, urinary; for use bar w/non-lck flng, w/fct-type tap w/vlv 2 pcY/12 mosOstomy pch, urinary; for use on bar w/lck flng 2 pcY/12 mosOstomy pch, urinary for use on bar w/lck flng, w/fct-type tap w.vlv 2 pcY/12 mosOstomy pch, drainable, high output, w/ext wear barrier(1 pc system) w or w/o filtereachY/12 mosADDITIONAL MISCELLANEOUS SUPPLIESTape, non-waterprof, per 18 square inchesY/12 mosTape, waterproof, per 18 square inchesY/12 mosAdhesive remover per ounceY/12 mosAdhesive remover wipes, eachY/12 mosMan Pump-Operated Enema Sys, Incl Balloon, Catheter & All Accessories, Reus, AnyTypeY/12 mosYSurgical dressing holder, reusable, eachY/12 mosTracheostoma filterY/12 mosMoisture exchange, disposable, for use w/invasive mech ventY/12 mosAbove Knee Length surgical stockingY/12 mosThigh Length surgical stockingY/12 mosBelow Knee Length surgical stockingY/12 mosFull Length surgical stockingY/12 mosYIncontinence garment, any type, (e.g. brief, diaper), eachY/12 mosYNon-disposable underpads, all sizesY/12 mosDisposable underpads, med size (e.g., Chux's)Y/12 mos100 every 2 mo100 every 2 mo100 every 2 mo100 every 2 mo60 every 2 mo100 every 2 mo120 every 2 mo60 every 2 mo100 every 2 mo60 every 2 mo60 every 2 3.343.123.5060 every 2 mo1/1/215.37800 every 2 mo800 every 2 mo20 every 2 mo200 every 2 mo7/1/207/1/207/1/207/1/200.070.331.330.22I/CI/C60 every 2 mo400 every 2 mo4 per yr4 per yr4 per yr4 per yrI/C4 every 2 mo135 per mo/100 per 391/1/211/1/217/1/2046.6822.150.68Conductive paste or gel, for use w/electrical device (e.g., TENS, NMES), per oz.Y/12 mos2 every 2 moSlingsY/12 mos2 per yrSplintY/12 mosY2 per yrTENS suppl 2 lead per moY/12 mos4 every 2 moSleeve for intermittent limb compression device, replacement only, eachY/12 mosYI/CLithium ion battery for non-prosthetic use, replacementY/12 mos1 per yrTubing with integrated heating element for use w/PAP deviceY/12 mos1 per yrTracheal Suction catheter, closed system, eachY/12 mos60 every 2 moOxygen Probe for use with oximeter device,Y/12 mos10 every 2 moSUPPLIES FOR OXYGEN AND RELATED RESPIRATORY EQUIPMENTTranstrachael oxygen catheter, eachY/12 mos10 every 2 moPeak expiratory flow rate meter, hand heldY/12 mos2 every 2 moCannula, NasalY/12 mos20 every 2 mo

Tubing (oxygen), per footFace tentVariable concentration maskTracheostomy inner cannulaTrach suction tubesTrach care kit for new trachTracheostomy cleaning brushSpacer, bag or reservior for inhalerOropharyngeal suction cathTracheostomy care kitY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosY/12 mosSUPPLIES FOR OTHER DURABLE MEDICAL EQUIPMENTRepl batteries t.e.n.s. owned by ptY/12 mosUnderarm crutch padY/12 mosRepl handgrip for cane etcY/12 mosRepl tip cane/crutch/walkerY/12 mosReplacement pad for use with medically necessary alternate pressure pad owned bypatientY/12 mosSyringe, with or without needle, eachY/12 mosBlood Pressure Apparatus w/cuff and stethoscopeY/12 mosBlood Pressure Cuff OnlyY/12 mosAutomatic Blood pressure monitorY/12 mosGloves, non-sterile (100 per box)Y/12 mosGloves, sterile, per pairY/12 mosOral thermometer, reusable, any type, eachY/12 mosRectal thermometer, reusable, any type, eachY/12 mosADDITIONAL OSTOMY SUPPLIESPouch clsd w barr attachedY/12 mosClsd ostomy pouch w/o barrY/12 mosClosed ostomy pouch faceplateY/12 mosClosed ostomy pouch w/flangeY/12 mosStoma capY/12 mosPouch drainable w barrier atY/12 mosOstomy pouch, drainable; w/o barrier attched (one piece) eaY/12 mosDrain ostomy pouch w/flangeY/12 mosUrinary pouch w/barrierY/12 mosUrinary pouch w/o barrierY/12 mosUrinary pouch on barr w/flngY/12 mosContinent stoma plugY/12 mosContinent stoma catheterY/12 mosOstomy accessory convex inseY/12 mosADDITIONAL INCONTINENCE APPLIANCES/SUPPLIESBedside drain btl w/wo tineY/12 mosUrinary suspensory, with or without leg bag, with or without tube, eachY/12 mosUrinary leg bagY/12 mos100 every 2 mo4 every 2 mo30 every 2 mo60 every 2 mo600 every 2 mo8 every 2 mo2 every 2 mo8 every 2 mo40 every 2 mo120 every 2 .332 per mo6 per yr10 per yr2/bx per yr1/1/211/1/211/1/211/1/211 per yr200 every 2 mo1 every 2 yrs1 every 2 yrs1 every 3 yrs10 bx every 2 mo400 every 2 mo1 per yr1 per 7/1/20120 every 2 mo200 every 2 mo60 every 2 mo100 every 2 mo60 every 2 mo120 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo200 every 2 mo60 every 2 mo60 every 2 mo60 every 2 671.343.291.942.525.593.292.963.0911.081.8210 every 2 mo10 every 2 mo20 every 2 .707.57

Latex leg strapY/12 mos2 every 2 moLeg strap; foam or fabric, replacement only, per setY/12 mos2 every 2 moSUPPLIES FOR EITHER INCONTINENCE OR OSTOMY APPLIANCESY/12 mosSkin Barrier, wipes or swabs, each500 every 2 moSolid skin barrier 6X6Y/12 mos120 every 2 moSolid skin barrier 8X8Y/12 mos72 every 2 moDisk/foam pad or adhesiveY/12 mos200 every 2 moAppliance cleanerY/12 mos4 every 2 moPercutaneous catheter anchorY/12 mos20 every 2 moDIABETIC SHOES, FITTING, AND MODIFICATIONSDiabetic shoe for density insert, per shoe2 per yrDiabetic custom molded shoe, per shoe2 per yrDiabetic shoe w/roller/rocker, per shoe2 per yrDiabetic shoe with wedge2 per yrDiabetic shoe w/metartarsal bar2 per yrDiabetic shoe w/offset heel2 per yrModification in diabetic shoe2 per yrDiabetic delux feature of off-the shelf depth inlay shoe or custom mld shoe2 per yrDrct formed, cmprss mold to pt's ft w/o ext, inserts, prefab, per sh, diabetY2 per yrMultiple density insert, for diabetics only, direct formed, molded to footY/12 mos2 per yrMultiple density insert, for diabetics only, custom molded from model of foot, incluarch fillerY/12 mos2 per yrMulti Den Insert, Direct Carv/CamY/12 mos2 per yrDRESSINGS, COMPRESSION GARMENTS, NEBULIZERS, PAP AND TRACH SUPPLIESCollagen based wound filler, dry form, per gram of collagenY/12 mos10 every 2 moCollagen based wound filler, gel/paste per gram of collagenY/3 mos60 every 2 moCollagen drsg. Size 16 sq inches or less, eachY/3 mos60 every 2 moCollagen drsg. more than 16 sq in but less than or equal to 48 sq inches, eachY/3 mos20 every 2 moCollagen drsg. more than 48 sq inches, eachY/3 mos20 every 2 moCollagen drsg. Wound filler, per 6 inY/3 mos216 every 2 moSilicone gel sheet, eachY/12 mosYI/CWound pouch eachY/3 mos40 every 2 moAlginate dressing 16 sq inY/3 mos100 every 2 moAlginate drsg 16 48 sq inY/3 mos40 every 2 moAlginate or other fiber gelling dressing, wound cover, 48 sq.in, each drsY/12 mos2 every 2 moAlginate drsg would fillerY/3 mos100 every 2 moComposite drsg 16 sq inY/3 mos400 every 2 moComposite drsg 16 48 sq inY/6 mos120 every 2 moComposite dressing, 48 sq.in., w/any size adh border, ea hc dressingY/12 mos400 every 2 moContact layer, 16 sq. in. or less, each dressingY/12 mos400 every 2 moContact layer 16 16 sq in w/o bdrY/6 mos400 every 2 moContact layer, 48 sq, in., each dressingY/12 mos400 every 2 moFoam drsg 16 sq in w/o bdrY/6 mos200 every 2 moFoam drsg 16 48 sq in w/o bdrY/6 mos300 every 2 1.469.976.8419.936.9618.56

A6255A6256A6257A6258Foam drg 48 sq in w/o brdrFoam drg 16 sq in w/borderFoam dressing, wound cover, pad 16 sq. but less than 48 sq. in w/ adh brdFoam drg 48 sq in w/borderFoam dressing, wound filler, per gramNon-steril gauze 16 sq inGauze, non-imprgn, non-strl, 16 sq.in., or to 48 sq.in, w/o adh brdrGauze, non-imprgn, non-strl, 48 sq. in., w/o adhesive border, each drsGauze 16 sq in w/borderGauze 16 48 sq in w/borderGauze, non-imprgn, 48 sq. in., w/any size adh border, each dressingGauze 16 in No w/sal w/o bGauze 16 48 no w/sal w/o bGauze 48 in no w/sal w/o bGauze, impregnated, water or normal saline, 16 sq. in. or less, w/o adhGauze 16 48 sq in watr/salGauze, impreg, water or normal saline, 48 sq. in., w/o adh borderGauze, hydrogel, 16 sq in. or less, eachGauze, impreg, hydrogel, for direct wound contact, 16 sq. in,Gauze, hydrogel, more than 48 sq inches, eachHydrocolld drg 16 w/o bdrHydrocolld drg 16 48 w/o bdrHydrocolld drg 48 in w/o bHydrocolld drg 16 in w/bdrHydrocolld drg 16 48 w/bdrHydrocolloid drssng, wound cover, pad 48 sq. in., w/any sz adh brdrHydroco

Maryland Medicaid DMS/DME Program Approved List of Items JANUARY 2021 HCPCS Description Prescription /CMN Frequency PA Limits Price Effective Date Rental Price (RR) Max Purchase Price (NU) A4206 Syringe w/needle 1cc each Y/12mos 250 every 2 mo 4/1/20 0.28 A4207 Syringe with needl