Page 135 - Medicare Benefit Policy Manual

Item Benefit Category Determination

(condition in which the natural lens has been removed but
there is no IOL), and congenital aphakia. Lenses provided
for other diagnoses will be denied as noncovered. Coverage
may be limited to one pair of eyeglasses or contact lenses.
Because coverage of refractive lenses is based upon the
prosthetic device benefit category, there is no coverage for
frames or lens add-on codes unless there is a covered
lens(es). Tinted lenses, including photochromatic lenses,
used as sunglasses, which are prescribed in addition to
regular prosthetic lenses to a pseudophakic beneficiary, will
be denied as noncovered.
Final determination established on 09-26-22.

Knee Ankle Foot Device, Leg Brace--Rigid device used for the purpose of supporting a
Any Material, Single or weak or deformed leg.
Double Upright, Swing Final determination established on 09-26-22.
and Stance Phase
Microprocessor Control
with Adjustability,
Includes All Components
(e.g., Sensors, Batteries,
Charger), Any Type
Activation, with or without
Ankle Joint(s), Custom
Fabricated

Low Frequency Ultrasonic No DMEPOS Benefit Category--Minimum lifetime
Diathermy Treatment requirement of at least three years not met. These items are
Device for Home Use not the standard pulses wave types of diathermy machines
referenced in section 280.1 of chapter 1, part 4 of the
National Coverage Determinations Manual. However, the
equipment must be able to be rented and used by multiple
patients for a minimum of three years in order to be
classified as DME.
Final determination established on 09-26-22.

Mechanical Allergen No DMEPOS Benefit Category--Minimum lifetime
Particle Barrier/Inhalation requirement of at least three years not met.
Filter, Cream, Nasal, Final determination established on 09-26-22.
Topical

Non-Invasive Vagus Nerve DME--These devices stimulate the cervical branch of the
Stimulator vagus nerve when applied to the side of the neck through two
stainless steel stimulation surfaces.