Page 134 - Medicare Benefit Policy Manual

Item Benefit Category Determination

Treatment Equipment, marketed for anti-snoring or other non-medical uses and all
With Sensor other requirements for classification as DME in accordance
with §414.202 are met.
Final determination established on 09-26-22.

Enema Tube, With or No DMEPOS Benefit Category--These items cannot
Without Adapter withstand repeated use and are therefore not DME. Rectal
catheters or tubes are not prosthetic devices because they do
not replace all or part of an internal body organ or all or part
of the function of a permanently inoperative or
malfunctioning internal body organ.
Final determination established on 09-26-22.

External Upper Limb DME--These devices deliver electrical stimulation to the
Tremor Stimulator of the nerves in the wrist to stimulate the peripheral nervous system
Peripheral Nerves of the for the treatment of essential tremors.
Wrist Final determination established on 09-26-22.

Foot Adductus Positioning Leg Brace--These are foot positioning devices that stabilize
Device, Adjustable the heel in the heel cage and the rest of the foot in the device
while applying corrective pressures to the midfoot, thereby
realigning the malformed pediatric foot. This is considered to
be an alternative to serial casting. The devices treat
newborns with semiflexible and rigid metatarsus
adductus/varus, as well as flexible metatarsus adductus/varus
that does not respond to stretching.
Final determination established on 09-26-22.

Hydrophilic, Dual Focus No DMEPOS Benefit Category--Contact lens used for the
Contact Lens correction of myopic ametropia and for slowing the
progression of myopia in children. These lenses do not
qualify as prosthetic devices under any of the categories for
prosthetic lenses under section 120.B of chapter 15 of the
Medicare Benefit Policy Manual.
Final determination established on 09-26-22.

Hydrophilic, Spherical Prosthetic Device--Refractive lenses are covered as
Contact Lens with prosthetic lenses under the benefit category for prosthetic
Photochromic Additive devices when they are used to restore the vision normally
provided by the natural lens of the eye of an individual
lacking the organic lens because of surgical removal or
congenital absence. Covered diagnoses are limited to
pseudophakia (condition in which the natural lens has been
replaced with an artificial intraocular lens [IOL]), aphakia