Medicaid Bulletin Colorado Title XIX

(1)

Automated Medical Payments

Medicaid Bulletin

Colorado Title XIX

Fiscal Agent

600 Seventeenth Street Suite 600 North Denver, CO 80202

Medicaid Provider Services

303-534-0146 1-800-237-0757

Mailing Addresses

Claims & PARs P.O. Box30 Denver, CO 80201-0030

Correspondence, Inquiries & Adjustments P.O Box 90 Denver, CO 80201-0090

Provider enrollment, Provider information, Changes, Signature authorization, and Claim requisitions P.O. Box 1100 Denver, CO 80201-1100

Medicaid Fiscal Agent Information on the Internet

http://coloradomedicaid.acs-inc.com

Medicaid bulletins contain important policy and billing information and should be shared promptly with billing staff.

Bulletins supplement information in the Medicaid Provider Manual and should be retained with the provider manual for reference. Retain all bulletins until published notification advises that the information is obsolete or reproduced in subsequent bulletins or provider manual updates.

Please direct questions about bulletins and billing information to Medicaid Provider Services.

Reference: B0200141 Classification of Enteral and Oral Formulas

T

he Colorado Medicaid Program has completed its review of enteral formulas and oral nutritional supplements. The review was done to insure that similar individual products were placed in the same categories.

The Department of Health Care Policy & Financing worked with providers to evaluate appropriate categories for these products. The review also showed the need for standardizing reimbursement for oral and enteral categories. The reimbursement for each of the HCPCS codes remains the same. The following individual products should be billed under the appropriate HCPCS code for its category.

The following Enteral and oral formula changes and additions are effective October 1, 2002:

The Pediatric Elemental Formulas listed below have been placed in Category V under HCPCS Code B4155:

Alimentum Nutramigen

Elecare Peptamen Junior

L-Emental Pediatirc Portagen Neocate Infant Pregestimil Neocate Junior Pro-Peptide For Kids Neocate One+Liquid Vivonex Pediatric Neocate One+Powder

The Standard Pediatric Products without fiber listed below have been placed in Category VI under HCPCS Code B4156:

Kindercal Pediasure

Kindercal TF Resource Just For Kids Nutren Jr

The Standard Pediatric Products with fiber listed below have been placed in Category III under HCPCS Code B4153:

Kindercal With Fiber Pediasure With Fiber Kindercal TF Fiber Resource Just For Kids With Fiber Nutren Jr With Fiber

The miscellaneous oral supplements and low-caloric content products listed below should be billed under HCPCS Code X4155. These products will continue to be reimbursed by-invoice:

Enlive NuBasics Juice Drink

Boos t Breeze Resource Fruit Beverage

Benefiber Promod

Casec Propac

Duocal Propac Plus

Egg/Pro Powder Rehydralyte

MCT Oil Resource Instant Protein Powder Microlipid Resource Thickened Juice

Moducal Resource Thicken-Up

Pedialyte Thick-It

Polycose

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2002 Supply HCPCS revised Appendix D

Also included with this bulletin is the revised Supply HCPCS Appendix D (Enteral Nutrition Product Classification List). Please replace Appendix D in Bulletin #B0200121, February 2002 with the attached Supply Appendix D, revised October 2002.

Product clarification:

PRODUCT NAME MANUFACTURER CATEGORY HCPCS CODE

Enfamil Lacto Free Mead Johnson I B4151

Ensure High Calcium Ross/Abbot Lab I B4150

Ketocal SHS I B4151

Kindercal Lacto Free Mead Johnson I B4151

These products have been added to the Supply HCPCS revised Appendix D.

Prior Authorization Requests (PARs) for nutritional supplements

Providers should continue to bill using the PAR that was originally approved for nutritional supplements. Submit a new PAR when the current PAR ends or when billing other codes requiring PARs.

Children’s extra large diapers

Providers billing for children’s extra large diapers should use procedure code X2022 (Youth brief). Do not bill extra large children’s diapers as an adolescent or child pull-up briefs.

Please direct questions about Medicaid billing or the information in this bulletin to:

Medicaid Provider Services at

303-534-0146 or 1-800-237-0757 (toll free Colorado).

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Effective for services rendered on and after October 1, 2002, prior authorization is no longer required for many prosthesis and orthosis codes. Providers are asked to continue providing these services to Medicaid clients only when medically necessary. The definition of medical necessity includes the requirement that the provided service be the least costly service or appliance that meets the client’s medical needs. The provider must maintain client records supporting medical necessity for a period of at least six (6) years from the date of service.

Procedure Code Description PAR Required

L0100 Cranial orthosis/helmet mold Always

L0110 Cranial orthosis/helmet nonm Always

L0120 cervical, flexible, non-adjustable Never

L0130 Cervical, flexible thermoplastic Always

L0140 Cervical, semi-rigid, adjustable Always

L0150 Cervical, semi-rigid, adjustable molded Always L0160 Cervical, semi-rigid, wire frame occipit Always L0170 Cervical, collar, molded to patient mode Always

L0172 Cerv collar semi-rigid 2 piece Always

L0174 Cerv collar semi-rigid foam 2pc w/thora Always L0180 Cervical, multiple post collar occipital Always L0190 Cervical, multiple post collar, occipita Always L0200 Cervical, multiple post collar, occipita Always L0210 Thoracic, rib belt, custom fitted Always L0220 Thoracic, rib belt, custom fabricated Always L0300 Thoracic, lumbar, sacral, orthoses (TLSO) Always L0310 TLSO, flexible (dorso, lumbar, surgical Always L0315 TLSO flex dorso lumbar support rigid pan Always

L0317 TLSO support hyperextension Always

L0320 TLSO, anterior anterior control (taylor Always

L0321 TLSO anti-post-cntrl prefab Always

L0330 TLSO, anterior anterior lateral (knight Always

L0331 TLSO ant-post-lat cntrl prfb Always

L0340 TLSO, anterior anterior lateral rotary Always L0350 TLSO, anterior anterior lateral rotary Always L0360 TLSO, anterior, anterior lateral rotary Always L0370 TLSO, anterior anterior lateral rotary Always

L0380 TLSO, anterior anterior lateral rotary Always L0390 TLSO, anterior anterior lateral control Always

L0391 TLSO ant-post-lat-rot cntrl Always

L0400 TLSO, anterior anterior lateral control Always L0410 TLSO ant-post-lat control 2 pc construct Always L0420 TLSO ant-post-lat control 2 pc w/interfa Always L0430 TLSO ant-post lat control custom fitted Always L0440 TLSO ant-post-lat control overlapping Always L0500 Lumbar sacral orthoses (LSO) flexible (l Never L0510 LSO, flexible, lumbo sacral surgical sup Never

L0515 LSO flex elas w/ rig post pa Never

L0520 LSO, anterior anterior lateral control, Never L0530 LSO, anterior anterior control, macausl Never L0540 LSO, lumbar flexion (william flexion typ Never L0550 LSO, anterior anterior lateral control, Never L0560 LSO, anterior anterior lateral control, Never

L0561 Prefab LSO Never

L0565 LSO ant-post lat control custom fitted Never L0600 Sacroiliac, flexible (sacroiliac surgica Never L0610 Sacroiliac, flexible (sacroiliac surgica Never L0620 Sacroiliac, semi-rigid (gold-thwaite, o Never L0700 Cervical thoracic lumbar sacral orthoses Never L0710 CTLSO, anterior anterior lateral contro Never L0810 Halo procedures, cervical halo incorpora Never L0820 Halo procedures, cervical halo incorpora Never L0830 Halo procedures, cervical halo incorpora Never L0860 Add to halo proc mri compatible system Never

(4)

L0900 Torso supports, ptosis support Never

L0910 Torso supports, ptosis support, custom f Never L0920 Torso supports, pendulous abdomen suppor Never L0930 Torso supports, pendulous abdomen suppor Never

L0940 Torso supports, post surgical Never

L0950 Torso supports, post surgical support, c Never L0960 Torso supports, post surgical support, p Never

L0970 TLSO, corset front Never

L0972 LSO, corset front Never

L0974 TLSO, full corset Never

L0976 LSO, full corset Never

L0978 Auxiliary crutch extension Never

L0980 Peroneal straps, pair Never

L0982 Stocking supporter grips, set of four (4 Never

L0984 Protective body sock each Never

L0986 Spinal orth abdm pnl prefab Never

L0999 Addition to spinal ortho nos Never

L1000 Cervical thoracic lumbar sacral (CTLSO) Never

L1005 Tension based scoliosis orth Never

L1010 Additions to cervical thoracic lumbar sa Never L1020 Additions to CTLSO or scoliosis orthoses Never L1025 Add to CTLSO or scoliosis orthosis Never L1030 Additions to CTLSO or scoliosis orthoses Never L1040 Additions to CTLSO or scoliosis orthoses Never L1050 Additions to CTLSO or scoliosis orthoses Never L1060 Additions to CTLSO or scoliosis orthoses Never L1070 Additions to CTLSO or scoliosis orthoses Never L1080 Additions to CTLSO or scoliosis orthoses Never L1085 Add to CTLSO or scoliosis orthosis bilat Never L1090 Additions to CTLSO or scoliosis orthoses Never L1100 Additions to CTLSO or scoliosis orthoses Never L1110 Additions to CTLSO or scoliosis orthoses Never

L1120 Additions to CTLSO or sio, scoliosis ort Never L1200 Thoracic lumbar sacral orthoses (TLSO) I Never L1210 Additions to TLSO , low profile, lateral Never L1220 Additions to TLSO, low profile, anterior Never L1230 Additions to TLSO, low profile, milwauke Never

L1240 Add to TLSO lumbar derotation pad Never

L1250 Add to TLSO ant asis pad Never

L1260 Add to TLSO ant thoracic derotation pad Never

L1270 Add to TLSO abdominal pad Never

L1280 Add to TLSO rib gusset each Never

L1290 Add to TLSO lat trochanteric pad Never

L1300 Other scoliosis procedures, body jacket Never L1310 Other scoliosis procedures, post operati Never

L1499 Spinal orthosis nos Never

L1500 Thoracic hip knee ankle, orthoses (THKAO Always

L1510 THKAO standing frame Always

L1520 THKAO, swivel walker Always

L1600 Abduct hip flex frejka w cvr Never

L1610 Abduct hip flex frejka covr Never

L1620 Abduct hip flex pavlik harne Never

L1630 Abduct control hip semi-flex Never

L1640 Pelv band/spread bar thigh c Never

L1650 HO abduction hip adjustable Never

L1660 HO abduction static plastic Never

L1680 Pelvic & hip control thigh c Never

L1685 Post-op hip abduct custom fa Never

L1686 HO post-op hip abduction Never

L1690 Combination bilateral ho Never

L1700 Leg perthes orth toronto typ Never

L1710 Legg perthes orth newington Never

L1720 Legg perthes orthosis trilat Never

L1730 Legg perthes orth scottish r Never

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L1750 Legg perthes sling Never

L1755 Legg perthes patten bottom t Never

L1800 Knee orthoses elas w stays Never

L1810 KO elastic with joints Never

L1815 Elastic with condylar pads Never

L1820 KO elas w/ condyle pads & jo Never

L1825 KO elastic knee cap Never

L1830 KO immobilizer canvas longit Never

L1832 KO adj jnt pos rigid support Never

L1834 KO w/o joint rigid molded to Never

L1840 KO derot ant cruciate custom Never

L1843 KO single upright custom fit Never

L1844 KO w/adj jt rot cntrl molded Never

L1845 KO w/ adj flex/ext rotat cus Never

L1846 KO w adj flex/ext rotat mold Never

L1847 KO adjustable w air chambers Never

L1850 KO swedish type Never

L1855 KO plas doub upright jnt mol Never

L1858 KO polycentric pneumatic pad Never

L1860 KO supracondylar socket mold Never

L1870 KO doub upright lacers molde Never

L1880 KO doub upright cuffs/lacers Never

L1885 Knee upright w/resistance Never

L1900 AFO sprng wir drsflx calf bd Never

L1902 AFO ankle gauntlet Never

L1904 AFO molded ankle gauntlet Never

L1906 AFO multiligamentus ankle su Never

L1910 AFO sing bar clasp attach sh Never

L1920 AFO sing upright w/ adjust s Never

L1930 AFO plastic Never

L1940 AFO molded to patient plasti Never

L1945 AFO molded plas rig ant tib Never

L1950 AFO spiral molded to pt plas Never

L1960 AFO pos solid ank plastic mo Never

L1970 AFO plastic molded w/ankle j Never

L1980 AFO sing solid stirrup calf Never

L1990 AFO doub solid stirrup calf Never

L2000 KAFO sing fre stirr thi/calf Never

L2010 KAFO sng solid stirrup w/o j Never

L2020 KAFO dbl solid stirrup band/ Never

L2030 KAFO dbl solid stirrup w/o j Never

L2035 KAFO plastic pediatric size Never

L2036 KAFO plas doub free knee mol Never

L2037 KAFO plas sing free knee mol Never

L2038 KAFO w/o joint multi-axis an Never

L2039 KAFO,plstic,medlat rotat con Never

L2040 HKAFO torsion bil rot straps Never

L2050 HKAFO torsion cable hip pelv Never

L2060 HKAFO torsion ball bearing j Never

L2070 HKAFO torsion unilat rot str Never

L2080 HKAFO unilat torsion cable Never

L2090 HKAFO unilat torsion ball br Never

L2102 AFO tibial fx cast plstr mol Never

L2104 AFO tib fx cast synthetic mo Never

L2106 AFO tib fx cast plaster mold Never

L2108 AFO tib fx cast molded to pt Never

L2112 AFO tibial fracture soft Never

L2114 AFO tib fx semi-rigid Never

L2116 AFO tibial fracture rigid Never

L2122 KAFO fem fx cast plas ter mol Never

L2124 KAFO fem fx cast synthet mol Never

L2126 KAFO fem fx cast thermoplas Never

L2128 KAFO fem fx cast molded to p Never

L2132 KAFO femoral fx cast soft Never

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L2134 KAFO fem fx cast semi-rigid Never

L2136 KAFO femoral fx cast rigid Never

L2180 Add to lower extrem frac orthosis shoe Never L2182 Adds to lower ext frac orthosis drop loc Never L2184 Add to lower ext frac orth limited motio Never L2186 Add to lower ext frac orthosis adj motio Never L2188 Add to lower ext frac orth quadrilateral Never L2190 Add to lower ext frac orth waist belt Never L2192 Add to low ext frac orth hip jt pelvic Never L2200 Additions to lower extremity, limited an Never L2210 Additions to lower extremity, dorsiflexi Never L2220 Additions to lower extremity, dorsiflexi Never L2230 Additions to lower extremity, split flat Never L2240 Additions to lower extremity, round cali Never L2250 Additions to lower extremity, foot plate Never L2260 Additions to lower extremity, reinforced Never L2265 Add lower extremity long tongue stirrup Never L2270 Additions to lower extremity, varus/valg Never

L2275 Add to lower ext padded lined Never

L2280 Additions to lower extremity, molded inn Never L2300 Additions to lower extremity, abduction Never L2310 Additions to lower extremity, abduction Never L2320 Additions to lower extremity, abduction Never L2330 Additions to lower extremity, lacer, mol Never L2335 Add to low ext anterior swing band Never L2340 additions to lower extremity, abduction Never L2350 additions to lower extremity, prosthetic Never L2360 Additions to lower extremity, abduction Never

L2370 Add to low ext patten bottom Never

L2375 Add to low ext torsion control ankle jt Never L2380 Add to low ext torsion control st knee Never L2385 Add to lower ext st knee jt heavy duty Never

L2390 Add to low ext offset knee jt ea jt Never L2395 Add to low ext offset jt heavy duty Never

L2397 Add to low ext orthosis Never

L2405 Add to knee jt drop lock each jt Never

L2415 Knee joint cam lock each joi Never

L2425 Add to kn jt disc or dial lock for adjus Never

L2430 Add knee jt - each joint Never

L2435 Add to kn jt polycentric jt ea jt Never

L2492 Add to kn jt lift loop for drop lock pin Never L2500 Additions to lower extremity, thigh weig Never L2510 Additions to lower extremity, thigh/weig Never L2520 Additions to lower extremity, thight/wei Never L2525 Add lower ext ischial contain/narrow m -l Never L2526 Add lower ext m-l brim custom fitted Never L2530 Additions to lower extremity, thigh/weig Never L2540 Additions to lower extremity, thigh/weig Never L2550 Additions to lower extremity, thigh/weig Never L2570 Additions to lower extremity, gluteal/is Never L2580 Additions to lower extremity, gluteal/is Never L2600 Additions to lower extremity, pelvic con Never L2610 Additions to lower extremity, pelvic con Never L2620 Additions to lower extremity, pelvic con Never L2622 Add to low ext pelvic control hip jt adj Never L2624 Add to low ext pelvic control hip adj ex Never L2627 Add low exs t reciprocating hip jt & cabl Never L2628 Add low ext pelvic control metal frame Never L2630 Additions to lower extremity, pelvic con Never L2640 Additions to lower extremity, pelvic con Never L2650 Additions to lower extremity, pelvic and Never L2660 Additions to lower extremity, thoracic c Never L2670 Additions to lower extremity, thoracic c Never L2680 Additions to lower extremity, thoracic c Never

(7)

L2750 Additions to lower extremity orthoses, p Never

L2755 Carbon graphite lamination Never

L2760 Additions to lower extremity orthoses, e Never

L2768 Ortho sidebar disconnect Never

L2770 Additions to lower extremity orthoses Never L2780 Additions to lower extremity, non-corres Never L2785 Add to low ext orth drop lock retainer e Never L2795 Add low ext orth knee control full knee Never L2800 Add low ext orth kn control knee cap Never L2810 Add to low ext orth kn control condylar Never L2820 Add low ext orth soft interface below kn Never L2830 Add to low ext orth soft interface above Never L2840 Add low ext orthosis tibial length sock Never L2850 Add low ext orth femerol length sock Never

L2860 Add to lower ext jt each Never

L2999 Lower extremity orthosis nos Never

L3000 Foot insert, removable, molded to patien Always L3001 Foot insert, removable, molded to patien Always L3002 Foot insert, removable, molded to patien Always L3003 Foot insert, removable, molded to patien Always L3010 Foot insert, removable, molded to patien Always L3020 Foot insert, removable, molded to patien Always L3030 Foot insert, removable, formed to patien Always L3040 Foot, arch support, removable, premolded Always L3050 Foot, arch support, removable, premolded Always L3060 Foot, arch support, removable, premolded Always L3070 Foot, arch support, non removable attach Always L3080 Foot, arch support, non removable attach Always L3090 Foot, arch support, non removable attach Always L3100 Hallus -valgus night dynamic splint Always

L3140 Foot rotation positioning device Always

L3150 Foot rotation position device w/o shoe Always

L3160 Foot adjustable shoe styled position Always L3170 Foot, abduction rotation bars (dennis br Always L3201 Orthopedic shoe, oxford with supinator o Never L3202 Orthopedic shoe, oxford with supinator o Never L3203 Orthopedic shoe, oxford with supinator o Never L3204 Orthopedic shoe, hightop with supinator Never L3206 Orthopedic shoe, hightop with supinator or Never L3207 Orthopedic shoe, hightop with supinator Never

L3208 Surgical boot, each, infant Never

L3209 Surgical boot, each, child Never

L3211 Surgical boot, each, junior Never

L3212 Benesch boot, pair, infant Never

L3213 Benesch boot, pair, child Never

L3214 Benesch boot, pair, junior Never

L3215 Orthopedic footwear, ladies shoes, oxfor Always L3216 Orthopedic footwear, ladies shoes, depth Always L3217 Orthopedic footwear, ladies shoes, hight Always L3218 Orthopedic footwear, ladies surgical boo Always L3219 Orthopedic footwear, men's shoes, oxford Always L3221 Orthopedic footwear, men's shoes, depth Always L3222 Orthopedic footwear, men's shoes, highto Always L3223 Orthopedic footwear, men's surgical boot Always

L3224 Orthopedic footwear womens brace Always

L3225 Ortho footwear mens shoe brace Always

L3230 Orthopedic footwear, custom shoes, depth Always L3250 Orthopedic footwear, custom molded shoes Always L3251 Foot-shoe molded to patient model, silic Always L3252 Foot-shoe molded to patient model, plast Always L3253 Foot-molded shoe plastozote or similar, Always

L3254 Not standard size or width Always

L3255 Not standard size or length Always

L3257 Orthopedic footwear add charge for split Always

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L3260 Ambulatory surgical boot, each Always

L3265 Plastazote sandal, each Always

L3300 Lifts, elevation, heel, tapered to matat Always L3310 Lifts, elevation, heel and sole, neopren Always L3320 Lifts, elevation, heel and sole, cork, p Always L3330 Lifts, elevation, metal extension skate Always L3332 Lifts, elevation, inside shoe, tapered, Always

L3334 Lift, elevation, heel, per inch Always

L3340 Heel wedge, sach Always

L3350 Heel wedge Always

L3360 Sole wedge, outside sole Always

L3370 Sole wedge, between sole Always

L3380 Clubfoot wedge Always

L3390 Outflare wedge Always

L3400 Metatarsal bar wedge, rocker Always

L3410 Metatarsal bar wedge, between sole Always L3420 Full sole and heel wedge, between sole Always

L3430 Heel counter, plastic reinforced Always

L3440 Heel counter, leather reinforced Always

L3450 Heel, sach cushion type Always

L3455 Heel, new leather, standard Always

L3460 Heel, new rubber, standard Always

L3465 Heel, Thomas with wedge Always

L3470 Heel, Thomas extended to ball Always

L3475 Heel-torque type Always

L3480 Heel, pad and depression for spur Always

L3485 Heel, pad, removable for spur Always

L3500 Ortho shoe add leather insol Always

L3510 Orthopedic shoe add rub insl Always

L3520 O shoe add felt w leath insl Always

L3530 Ortho shoe add half sole Always

L3540 Ortho shoe add full sole Always

L3550 O shoe add standard toe tap Always

L3560 O shoe add horseshoe toe tap Always

L3570 O shoe add instep extension Always

L3580 O shoe add instep velcro clo Always

L3590 O shoe convert to sof counte Always

L3595 Ortho shoe add march bar Always

L3600 Transfers of an orthosis from one shoe t Always L3610 Transfers of an orthosis from one shoe t Always L3620 Transfers of an orthosis from one shoe t Always L3630 Transfers of an orthosis from one shoe t Always L3640 Transfers of an orthosis from one shoe t Always L3640 Transfers of an orthosis from one shoe t Always

L3649 Orthopedic shoe modifica nos Always

L3650 Shlder fig 8 abduct restrain Never

L3660 Abduct restrainer canvas&web Never

L3670 Acromio/clavicular canvas&we Never

L3675 Canvas vest so Never

L3677 SO hard plastic stabilizer Never

L3700 Elbow orthoses elas w stays Never

L3710 Elbow elastic with metal joi Never

L3720 Forearm/arm cuffs free motio Never

L3730 Forearm/arm cuffs ext/flex a Never

L3740 Cuffs adj lock w/ active con Never

L3760 EO with joint, prefabricated Never

L3800 WHFO short opponen no attach Never

L3805 WHFO long opponens no attach Never

L3807 WHFO,no joint, prefabricated Never

L3810 WHFO, additions to short and long oppone Never L3815 WHFO, additions to short and long oppone Never L3820 WHFO, addition to short and long opponen Never L3825 WHFO, additions to short and long oppone Never L3830 WHFO, additions to short and long oppone Never

(9)

L3835 WHFO, additions to short and long oppone Never L3840 WHFO, additions to short and long oppone Never L3845 WHFO, additions to short and long oppone Never L3850 WHFO, additions to short and long oppone Never L3855 WHFO, additions to short and long oppone Never L3860 WHFO, additions to short and long oppone Never

L3890 Add to upper ext jt each Never

L3900 Hinge extension/flex wrist/f Never

L3901 Hinge ext/flex wrist finger Never

L3902 WHFO ext power compress gas Never

L3904 WHFO electric custom fitted Never

L3906 Wrist gauntlet molded to pt Never

L3907 WHFO wrst gauntlt thmb spica Never

L3908 Wrist cock-up non-molded Never

L3910 WHFO swanson design Never

L3912 Flex glove w/elastic finger Never

L3914 WHO wrist extension cock-up Never

L3916 WHFO wrist extens w/ outrigg Never

L3918 HFO knuckle bender Never

L3920 Knuckle bender with outrigge Never

L3922 Knuckle bend 2 seg to flex j Never

L3923 HFO, no joint, prefabricated Never

L3924 Oppenheimer Never

L3926 Thomas suspension Never

L3928 Finger extension w/ clock sp Never

L3930 Finger extension with wrist Never

L3932 Safety pin spring wire Never

L3934 Safety pin modified Never

L3936 Palmer Never

L3938 Dorsal wrist Never

L3940 Dorsal wrist w/ outrigger at Never

L3942 Reverse knuckle bender Never

L3944 Reverse knuckle bend w/ outr Never

L3946 HFO composite elastic Never

L3948 Finger knuckle bender Never

L3950 Oppenheimer w/ knuckle bend Never

L3952 Oppenheimer w/ rev knuckle 2 Never

L3954 Spreading hand Never

L3956 Add joint to upper ext - per joint Never

L3960 SEWHO airplan desig abdu pos Never

L3962 SEWHO erbs palsey design abd Never

L3963 Molded w/ articulating elbow Never

L3964 SEO mobile arm sup att to wc Never

L3965 Arm supp att to wc rancho ty Never

L3966 Mobile arm supports reclinin Never

L3968 Friction dampening arm supp Never

L3969 Monosuspension arm/hand supp Never

L3970 SEWHO, additions to mobile arm supports, Never L3972 SEWHO, additions to mobile arm supports, Never L3974 SEWHO, additions to mobile arm supports, Never

L3980 Upp ext fx orthosis humeral Never

L3982 Upper ext fx orthosis rad/ul Never

L3984 Upper ext fx orthosis wrist Never

L3985 Forearm hand fx orth w/ wr h Never

L3986 Humeral rad/ulna wrist fx or Never

L3995 Add upper ext ortho sock frac or equal e Never

L3999 Upper limb orthosis nos Never

L4000 Repl girdle milwaukee orth Never

L4010 Replace trilateral socket brim Never

L4020 Replace quadrilateral socket brim, molde Never L4030 Replace wuadrilateral socket brim, custo Never

L4040 Replace molded thigh lacer Never

L4045 Replace non-molded thigh lacer Never

L4050 Replace molded calf lacer Never

(10)

L4055 Replace non molded calf lacer Never

L4060 Replace high roll cuff Never

L4070 Replace proximal and distal upright for Never L4080 Replace metal bands "KAFO-afo", proximal Never L4090 Replace metal bands "KAFO-afo', calf or Never L4100 Replace metal bands 'KAFO-afo', proximal Never L4110 Replace leather cuff "KAFO-afo" , calf o Never

L4130 Replace pretibial shell Never

L4205 Repair orthotic labor per 15 min Never

L4210 Repair of orthotic device, repair or rep Never

L4350 Pneumatic ankle cntrl splint Never

L4360 Pneumatic walking splint Never

L4370 Pneumatic full leg splint Never

L4380 Pneumatic knee splint Never

L4392 Replace AFO soft interface Never

L4394 Replace - inter mat-foot drop splint Never

L4396 Static AFO Never

L4398 Foot drop splint recumbent Never

L5000 Partial foot, shoe insert with longitudi Never L5010 Partial foot, molded socket, ankle heigh Never L5020 Partial foot molded socket tibial tuberc Never

L5050 Ankle symes molded socket Never

L5060 Ankle, symes, metal frame, molded leathe Never L5100 Below knee, molded socket, shin, sach fo Never L5105 Below kn plastic socket jts & thigh lace Never L5150 Knee disarticulation, or throught knee, Never L5160 Knee disarticulation, or through knee, m Never L5200 Above knee, molded socket, single axis c Never L5210 Above knee, short prosthesis, no knee jo Never L5220 Above knee, short prosthesis, no knee jo Never L5230 Above knee, for proximal femoral focal d Never L5250 Hip disarticulation, canadian, type; mol Never

L5270 Hip disarticulation, tilt table type, mo Never L5280 Hemipetvectomy, canadian type, molded so Never

L5301 Bk mold socket sach ft endo Never

L5311 Knee disart, sach ft, endo Never

L5321 Ak open end sach Never

L5331 Hip disart canadian sach ft Never

L5341 Hemipelvectomy canadian sach Never

L5400 Immediate post surgical or early fitting Never L5410 Immediate post surgical or early fitting Never L5420 Immediate post surgical or early fitting Never L5430 Immediate post surgical or early fitting Never L5450 Immediate post s urgical or early fitting Never L5460 Immediate post surgical or early fitting Never L5500 Preparatory, below knee (ptb type socket Never L5505 Preparatory, above knee, knee disarticul Never L5510 Preparatory, below knee (ptb type socket Never L5520 Preparatory, below knee (ptb type socket Never L5530 Preparatory, below knee (ptb type socket Never L5535 PTB sach foot prefab adj open end socket Never L5540 Preparatory, below knee (ptb type socket Never L5560 Preparatory, above knee-knee disarticula Never L5570 Preparatory, above knee-knee disarticula Never L5580 Preparatory, above knee-knee disarticula Never L5585 Prepar above kn-kn disarticulation usmc Never L5590 Preparatory, above knee-knee disarticula Never L5595 Hip-disart-hemi pylon molded to pt model Never L5600 Hip-disart-hemi pylon laminated socket Never L5610 Additions to lower extremity, above knee Never

L5611 Add lower ext above knee disartic Never

L5613 Add lower ext--- w/ hydraulic swing pha Never L5614 Additions to lower extremity, above knee Never L5616 Additions to lower extremity, above knee Never

(11)

L5617 Add low extrem--knee each Never

L5618 Additions to lower extremity, test socke Never L5620 Additions to lower extremity, test socke Never L5622 Additions to lower extremity, test socke Never L5624 Additions to lower extremity, test socke Never L5626 Additions to lower extremity, test socke Never L5628 Additions to lower extremity, test socke Never L5629 Add to low ext below knee acrylic socket Never L5630 Additions to lower extremity, symes type Never L5631 Add to low ext above kn or kn disart acr Never L5632 Additions to lower extremity, symes type Never L5634 Additions to lower extremity, symes type Never L5636 Additions to lower extremity, symes type Never L5637 Add low ext below knee total contact Never L5638 Additions to lower extremity, below knee Never L5639 Addition to low extr, bk, wood socket Never L5640 Additions to lower extremity, knee disar Never L5642 Additions to lower extremity, above knee Never L5643 Add tolower ext hip disart flex inner Never L5644 Additions to lower extremity, above knee Never L5645 Add to ext below kn flex inner socke Never L5646 Additions to lower extremity, below knee Never L5647 Add low ext below kn suction socket Never L5648 Additions to lower extremity, above knee Never

L5649 Add low cat-cam socket Never

L5650 Additions to lower extremity, total cont Never L5651 Add low ext above kn flex inner socket Never L5652 Additions lower extremity suction susp. Never L5653 Additions to lower extremity, knee disar Never L5654 Additions to lower extremity, socket ins Never L5655 Additions to lower extremity, socket ins Never L5656 Additions to lower extremity, socket ins Never

L5658 Additions to lower extremity, socket ins Never L5660 Additions to lower extremity, socket ins Never L5661 Add lower ext socket insert multi-durom Never L5662 Additions to lower extremity, socket ins Never L5663 Additions lower extremity socket insert Never L5664 Additions to lower extremity, socket ins Never

L5665 Add lower ext socket insert knee Never

L5666 Additions to lower extremity, below knee Never

L5668 Addition to lower ext. b/k Never

L5670 Additions lower extremity bk molded supr Never

L5671 Bk/ak locking mechanism Never

L5672 Additions lower extremity bk removeable Never

L5674 Bk suspension sleeve Never

L5675 Bk heavy duty susp sleeve Never

L5676 Additions lower extremity bk knee joints Never L5677 Add lower ext below kn polycentric pair Never L5678 Additions lower extremity bk joint cover Never L5680 Additions lower extremity bk thigh lacer Never L5682 Additions lower extremity bk thigh lacer Never L5684 Additions lower extremity bk fork strap Never L5686 Additions lower extremity bk back check Never L5688 Additions lower extremity bk waist belt Never L5690 Additions lower extremity bk waist belt Never L5692 Additions lower extremity ak pelvic belt Never L5694 Additions lower extremity ak pelvic belt Never

L5695 Add to low ext above knee each Never

L5696 Additions lower extremity ak/knee disart Never L5697 Additions lower extremity ak/knee disart Never L5698 Additions lower extremity ak/knee disart Never L5699 All lower extremity prosthesis shoulder Never

L5700 Replace socket below knee Never

L5701 Replace socket above knee/knee Never

(12)

L5702 Replace socket hip disareticulation Never

L5704 Custom shape cover bk Never

L5705 Custom shape cover ak Never

L5706 Custom shape cvr knee disart Never

L5707 Custom shape cvr hip disart Never

L5710 Additions knee-shin system single axis Never L5711 Add exoskeletal knee shin sys single axi Never L5712 Additions knee-shin system single axis Never L5714 Additions knee-shin system single axis Never L5716 Additions knee-shin system polycentric Never L5718 Additions knee-shin system polycentric Never L5722 Additions knee-shin system single axis Never L5724 Additions, knee-shin system, single axis Never L5726 Additions, knee-shin system, single axis Never L5728 Additions, knee-shin system, single axis Never L5780 Additions, knee-shin system, single axis Never L5785 Adds exoskeletal sys below kn ultra-ligh Never L5790 Add exoskeletal sys above kn ultra-light Never L5795 Add exoskeletal sys hip disarticulation Never L5810 Add endoskeletal knee-shin sys single ax Never L5811 Add endoskeletal kn-shin sys single ultr Never L5812 Add endoskeletal kn-sh sys friction swin Never

L5814 Add knee - shin sys - phase lock Never

L5816 Add endoskel kn-shin sys polycentric mec Never L5818 Add endo kn-shin sys polycen friction sw Never L5822 Add endo kn-shin sys sin axis pneumatic Never L5824 Add endo kn-shin system single axis flui Never

L5826 Add ebdiskel knee - shin system Never

L5828 Add endo kn-shin sys sin fluid swing Never L5830 Add endoskel kn-shin sys singl axis pneu Never

L5840 Multi-axial knee/shin system Never

L5845 Add - knee - shin - sys - adj Never

L5846 Add - knee, shin, sys, swing phase only Never

L5847 Microprocessor cntrl feature Never

L5850 Add endoskeletal sys above knee or hip Never

L5855 Add hip disarticulation Never

L5910 Add endoskelital sys below kn align able Never L5920 Add endoskeletal sys above kn or hip dis Never

L5925 Above knee manual lock Never

L5930 Add - hi activity knee control fra Never L5940 Add endoskeletal sys below kn alignable Never L5950 Add endoskeletal sys above kn ultra-ligh Never L5960 Add endo system hip disarticulation ultr Never

L5962 Add below knee system Never

L5964 Add above knee system Never

L5966 Add hip disarticulation Never

L5968 Multiaxial ankle w dorsiflex Never

L5970 All low ext pros foot ext keel sach foot Never

L5972 All low ext pros flex keel ft Never

L5974 All low ext pros foot single axis ankle/ Never

L5975 Combo ankle/foot prosthesis Never

L5976 All low ext pros energy storing foot Never L5978 All low ext pros foot multiaxial ankle/f Never

L5979 Multi-axial ankle/ft prosth Never

L5980 All lower ext pros flex foot system Never

L5981 All lower ext pros Never

L5982 All exoskeletal low ext pros axial rotat Never L5984 All endoskeletal low ext pros axia rotat Never

L5985 All endo low pros dyn prost pylon Never

L5986 All low ext pros multi-axial rotation un Never L5987 All lower ext pros - shank foot sys Never

L5988 Vertical shock reducing pylo Never

L5989 Pylon w elctrnc force sensor Never

L5990 User adjustable heel height Never

(13)

L5999 Lower extremity prosthesis nos Never

L6000 Partial hand, robin-aids, thumb remainin Never L6010 Partial hand, robin-aids, little and/or Never L6020 Partial hand, robin-aids, no finger rema Never L6050 Wrist disarticulation, molded socket, fl Never L6055 Wrist disarticulation molded socket tric Never L6100 Below elbow, molded socket, flexible elb Never L6110 Below elbow, molded socket, (muenster or Never L6120 Below elbow, molded double wall split so Never L6130 Below elbow, molded double wall split so Never L6200 Elbow disarticulation, molded socket, ou Never L6205 Elbow disarticulation outside locking hi Never L6250 Above elbow molded double wall socket Never L6300 Shoulder disarticulation, molded socket, Never L6310 Shoulder disarticulation, passive restor Never L6320 Shoulder disarticulation, passive restor Never L6350 Interscapular thoracic, molded socket, s Never L6360 Interscapular thoracic, passive restorat Never L6370 Interscapular thoracic, passive restorat Never L6380 Upper limb immediate & early post surg Never L6382 Imm post-surg or early fitting app of in Never L6384 Imm post surg or early fit app of initia Never L6386 Imm post surg or early ftt ea add cast c Never L6388 Imm post surg or early ftt app of rigid Never L6400 Below elbow, molded socket, endoskeletal Never L6450 Elbow disarticulation, molded socket, en Never L6500 Above elbow, molded socket, endoskeletal Never L6550 Shoulder disarticulation, molded socket, Never L6570 Interscapular thoracic, molded socket, e Never L6580 Prep wrist disarticulation or below elbo Never L6582 Prepar wrist disarticulation direct form Never L6584 Prepar elbow disart molded to pt model Never

L6586 Prepar elbow disart direct formed Never

L6588 Prepar shoulder disart chest strap Never L6590 Shoulder disart or interscapular direct Never L6600 Upper extremity additions, polycentric h Never L6605 Upper extremity additions, single pivot Never L6610 Upper extremity additions, flexible meta Never L6615 Upper extremity additions, disconnect lo Never L6616 Upper ext add,additional dis insert wris Never L6620 Upper extremity additions, flexion-frict Never L6623 Upper extremity addition spring assist Never L6625 Upper extremity additions, rotation wris Never L6628 Upper ext add quick disconnect hook adap Never L6629 Upper ext add quick disconnect laminatio Never L6630 Upper extremity additions stainless stee Never L6632 Up extremity add latex suspension sleeve Never L6635 Upper extremity additions, life assist f Never L6637 Upper ext addition nudge control elbow Never L6640 Upper extremity additions, shoulder abdu Never L6641 Upper ext add excursion amplifier pulley Never L6642 Upper ext add excursion amplifier lever Never L6645 Upper extremity additions, shoulder flex Never L6650 Upper extremity additions, shoulder univ Never L6655 Upper extremity additions, standard cont Never L6660 Upper extremity additions, heavy duty co Never L6665 Upper extremity additions, teflon, or eq Never L6670 Upper extremity additions, hook to hand, Never L6672 Upper extremity additions, harness, ches Never L6675 Upper extremity additions, harness, figu Never L6676 Upper extremity additions, harness, figu Never L6680 Upper extremity additions, test socket, Never L6682 Upper extremity additions, test socket, Never L6684 Upper extremity additions, test socket, Never

(14)

L6686 Upper extremity addition suction socket Never L6687 Upper ext add frame type socket below el Never L6688 Upper ext add frame type socket above el Never L6689 Upper ext add frame type socket shoulder Never L6690 Upper ext add frame type socket intercap Never L6691 Upper extrem add removable insert ea Never L6692 Upper ext addition silicone gel insert e Never

L6693 Locking elbow forearm cntrbal Never

L6700 Terminal device, hooks, dorrance, or equ Never L6705 Terminal device, hooks, dorrance, or equ Never L6710 Terminal devices, hooks, dorrance, or eq Never L6715 Terminal devices, hooks, dorrance, or eq Never L6720 Terminal devices, hooks, dorrance, or eq Never L6725 Terminal devices, hooks, dorrance, or eq Never L6730 Terminal devices, hooks, dorrance, or eq Never L6735 Terminal devices, hooks, dorrance, or eq Never L6740 Terminal devices, hooks, dorrance, or eq Never L6745 Terminal devices, hooks, dorrance, or eq Never L6750 Terminal devices, hooks, dorrance, or eq Never L6755 Terminal devices, hooks, dorrance, or eq Never L6765 Terminal devices, hooks, dorrance, or eq Never L6770 Terminal devices, hooks, dorrance, or eq Never L6775 Terminal devices, hooks, dorrance, or eq Never L6780 Terminal devices, hooks, dorrance, or eq Never L6790 Terminal devices, hooks, dorrance, or eq Never L6795 Terminal devices, hooks, dorrance, or eq Never L6800 Terminal devices, hooks, dorrance, or eq Never L6805 Terminal devices, modifier, wrist flexio Never

L6806 Terminal device hook trs grip vc Never

L6807 Terminal device hook grip Never

L6808 Terminal device hook trs adept infant vc Never L6809 Terminal device hook trs super sport Never

L6810 Terminal device pincher tool otto bock Never L6825 Terminal devices, hand, dorrance, vo (vo Never L6830 Terminal devices, hand, aprl, vc (volunt Never L6835 Terminal devices, hand, sierra, vo Never L6840 Terminal devices, hand, becker imperial Never L6845 Terminal devices, hand, becker lock grip Never L6850 Terminal devices, hand, becker plylita Never L6855 Terminal devices, hand, robin-aids, vo Never L6860 Terminal devices, hand, robin-aids, vo s Never L6865 Terminal devices, hand, passive hand Never L6867 Terminal device hand detroit infant hand Never

L6868 Term device hand passive inf hand Never

L6870 Terminal devices, hand, child mitt Never

L6872 Term device hand nyu child hand Never

L6873 Term device hand mechanical inf hand ste Never

L6875 Terminal devices, hand, bock, vc Never

L6880 Terminal devices, hand, bock, vo Never

L6881 Autograsp feature ul term dv Always

L6882 Microprocessor control uplmb Always

L6890 Terminal device, gloves for above hands, Always L6895 Terminal devices, gloves for above hands Always L6900 Hand restoration (casts, shading and mea Always L6905 Hand restoration (casts, shading and mea Always L6910 Hand restoration (casts, shading and mea Always L6915 Hand restoration (shading, and measureme Always

L6920 Wrist disarticulation ext power Never

L6925 Wrist disart ext power self suspended my Never L6930 Below elbow ext power switch control Never L6935 Below elbow ext power equal electrodes Never L6940 Elbow disarticulation switch control Never L6945 Elbow disarticulation ext power myoelect Never L6950 Above elbow ext power switch control Never

(15)

L6955 Above elbow ext power myoelectronic cont Never L6960 Shoulder disart ext power switch control Never L6965 Shoulder disart myoelectronic control Never L6970 Intercapular-thoracic switch control Never L6975 Intercapsular thoracic myoelectronic Never L7010 Electronic hand otto bock steeper or equ Never L7015 Electronic hand system teknik variety vi Never L7020 Electronic griefer otto bock or equal Never L7025 Elect hand otto bock or equal myoelectro Never L7030 Elect hand system teknik myoelectronical Never L7035 Elect greifer otto bock or equal myoelec Never L7040 Prehensile actuator hosmer switch contro Never L7045 Electronic hook child michigan or eq swt Never L7170 Electronic elbow hosmer or equal switch Never

L7180 Electronic elbow utah Never

L7185 Electronic elbow variety switch controll Never L7186 Electronic elbow child variety village Never L7190 Electronic elbow variety village myoelec Never L7191 Elect elbow child--myoelectronically con Never L7260 Electronic wrist rotator otto bock Never L7261 Electronic wrist rotator for utah arm Never

L7266 Servo control steeper or equal Never

L7272 Analogue control unb or equal Never

L7274 Proportional control 6-12 volt Never

L7360 Six volt battery otto bock each Never

L7362 Battery charger six volt otto bock or eq Never L7364 12 volt battery utah or equal each Never L7366 Battery charger 12 volt utah or equal Never

L7499 Upper extremity prosthesis nos Never

L7500 Prosthetic repair per hour Never

L7510 Repair prosthetic device, repair or repl Never L7520 Repair pros dev labor com per 15 min Never

L7900 Vacuum erection system Always

L8000 Breast prosthesis, mastectomy bra Never

L8001 Breast prosthesis bra & form Never

L8002 Brst prsth bra & bilat form Never

L8010 Breast prosthesis, mastectomy sleeve Never

L8015 Ext breast prosthesis garment Never

L8020 Breast prosthesis, mastectomy form (exte) Never L8030 Breast prosthesis silicone or equal Never

L8035 Custom breast prosthesis Never

L8039 Breast prosthesis nos Never

L8040 Nasal prosthesis, provided by a non-physician Always L8041 Midfacial prosthesis, provided by a non-physician Always

L8042 Orbital prosthesis Always

L8043 Upper facial prosthesis Always

L8044 Hemi-facial prosthesis Always

L8045 Auricular prosthesis Always

L8046 Partial facial prosthesis Always

L8047 Nasal septal prosthesis Always

L8048 Unspec maxillofacial prosth Always

L8049 Repair maxillofacial prosth Always

L8100 Elastic supports, elastic stockings, bel Never L8110 Elastic supports, elastic stockings, bel Never L8120 Elastic supports, elastic stockings, bel Never L8130 Elastic supports, elastic stockings, abo Never L8140 Elastic supports, elastic stockings, abo Never L8150 Elastic supports, elastic stockings, abo Never L8160 Elastic supports, elastic stockings, ful Never L8170 Elastic supports, elastic stockings, ful Never L8180 Elastic supports, elastic stockings , ful Never L8190 Elastic supports, elastic stockings, leo Never

L8195 GC stocking waistlngth 30-40 Never

L8200 Elastic supports, elastic stockings, leo Never

(16)

L8210 GC stocking custom made Never

L8220 GC stocking lymphedema Never

L8230 GC stocking garter belt Never

L8239 G compression stocking nos Never

L8300 Trusses, single with standard pad Never

L8310 Trusses, double with standard pads Never L8320 Trusses, addition to standard pads, wate Never L8330 Trusses, addition to standard pads, scro Never L8400 Prosthetic sheath, below knee, each Never L8410 Prosthetic sheath, above knee, each Never

L8415 Prosthetic sheath upper limb each Never

L8417 Pros sheath/sock each Never

L8420 Prosthetic sock multi ply bk Never

L8430 Prosthetic sock multi ply ak Never

L8435 Pros sock multi ply upper lm Never

L8440 Prosthetic shrinker, below knee, each Never L8460 Prosthetic shrinker, above knee, each Never L8465 Prosthetic shrinker upper limb each Never

L8470 Pros sock single ply bk Never

L8480 Pros sock single ply ak Never

L8485 Pros sock single ply upper l Never

L8490 Add prosth sheath/sock system Never

L8499 Unlisted misc prosthetic ser Always

L8500 Artificial larynx Never

L8501 Tracheostomy speaking valve Never

L8505 Artificial larynx, accessory Always

L8507 Trach-esoph voice pros pt in Always

L8509 Trach-esoph voice pros md in Always

L8510 Voice amplifier Always

L8600 Implantable breast prosthesis silicone Never

L8603 Collagen imp urinary 2.5 ml Never

L8606 Synthetic implnt urinary 1ml Never

L8610 Ocular implant Always

L8612 Aqueous shunt Never

L8613 Ossicula implant Never

L8614 Cochlear device/system Always

L8619 Cochlear implant processor - replace Always

L8630 Metacarpophalangeal joint implant Never

L8641 Metatarsal joint implant Never

L8642 Hallux implant Never

L8658 Interphalangeal joint implant Never

L8670 Vascular graft mat synth implant Never

L8699 Prosthetic implant nos Always

L9900 O & P supply/accessory/service Always

(17)

Reference: # B0200141 (Revised 10/02) Page D-1

PRODUCT NAME MANUFACTURER CATEGORY CODE

Accupepha Nutrica-NV-Verenigde III B4153

Acerflex SHS IV B4154

Advera Ross Labs IV B4154

Alimentum Ross Labs V B4155

Alitraq Ross Labs IV B4154

Alsoy Nestle Clinical Nutrition I B4150

AminAid McGraw IV B4154

AMTF Nyer Nutritional Systems I B4150

AMTF Diabetic Nyer Nutritional Systems I B4150

AMTF High Cal 2.0 Nyer Nutritional Systems II B4152

AMTF High Protein Nyer Nutritional Systems I B4150

AMTF Pediatric Nyer Nutritional Systems I B4150

AMTF Pulmonary Nyer Nutritional Systems II B4152

AMTF Renal Nyer Nutritional Systems IV B4154

AMTF Renal 2.0 Nyer Nutritional Systems II B4152

AMTF Trauma Nyer Nutritional Systems IV B4154

Analog formulas Analog XP Analog MSUD Analog XPHEN, TYR Analog XPTM Analog XMTVI Analog XMET Analog XLYS, TRY Analog XLEU

SHS IV B4154

Balanced- The Total Nutritional Drink (Instant Meal Replacement Drink)

American Natural Snacks I B4150

Balanced- The Total Nutritional Drink (Ready to Drink Meal)

American Natural Snacks I B4150

Benefiber Novartis Nutrition V X4155

Boost or Boost High Protein Mead Johnson I B4150

Boost Breeze Mead Johnson V X4155

Boost Plus Mead Johnson II B4152

Boost Pudding Mead Johnson I B4150

Boost with Fiber Mead Johnson I B4150

Calcilo XD Ross Labs IV B4154

Casec Mead Johnson V X4155

Choice DM Mead Johnson IV B4154

Choice DM Bars Mead Johnson IV B4154

Citrotein Novartis Nutrition IV B4154

Complete-B Novartis Nutrition I B4151

Complete-B Modified Novartis Nutrition I B4151

Complete Pediatric Novartis Nutrition I B4151

Comply Mead Johnson II B4152

Criticare HN Mead Johnson III B4153

Crucial Complete Elemental Diet (Re-Review)

Nestle Clinical Nutrition III B4153

Deliver 2.0 Mead Johnson II B4152

DiabetiSource Novartis Nutrition IV B4154

(18)

Duocal SHS V X4155

Duocal (Super Soluble) SHS V B4155

Egg/Pro Powder Ross Labs V X4155

EleCare Ross Labs V B4155

Elementra Nestle Clinical Nutrition V B4155

Enfamil Mead Johnson I B4150

Enfamil A.R. Mead Johnson I B4150

Enfamil Kindercal TF Mead Johnson I B4150

Enfamil LactoFree Mead Johnson I B4151

Enfamil with Iron Mead Johnson I B4150

Enfacare Mead Johnson I B4150

Enlive Ross Labs V X4155

Ensure Ross Labs I B4150

Ensure HN Ross Labs I B4150

Ensure HP Ross Labs I B4150

Ensure High Calcium Ross Labs I B4150

Ensure Plus Ross Labs II B4152

Ensure Plus HN Ross Labs II B4152

Ensure Powder Ross Labs I B4150

Ensure Pudding Ross Labs I B4150

Ensure with Fiber Ross Labs I B4150

Entera Fresenius Medical I B4150

Entera Isotonic Fresenius Medical I B4150

Entera Isotonic Fiber Fresenius Medical I B4150

Entera OPD Smash-Fresenius IV B4154

Enteralife HN Corpac I B4150

Enteralife HN Fiber Corpac I B4150

Enteralife HN-2 Corpac I B4150

Entrition 1.5 Nestle Clinical Nutrition II B4152

Entrition HN Nestle Clinical Nutrition I B4150

EPULOR (Re-Review)

VistaPharm V B4155

Essential ProPlus NutriSOY V B4155

Essential Protein NutriSOY V B4155

F.A.A. (Free Amino Acid Diet) Nestle Clinical Nutrition III B4153

Fiber 7 ND Labs, Inc. A9270

Fiberlan Elan/Hechems I B4150

Fibersource Novartis Nutrition I B4150

Fibersource HN Novartis Nutrition I B4150

Fibrad Ross Labs V B4155

Follow-up Nestle Clinical Nutrition I B4150

Follow-up Soy Nestle Clinical Nutrition I B4150

Fortison Nutrica-NV-Verenigde I B4150

Fulfil Fresenius Medical IV B4154

Genisoy Protein Bars Genisoy I B4150

Glucerna Ross Labs IV B4154

Gluco-Pro GalaGen, Inc. IV B4154

Glutamine Enriched Antioxidant Formula Cambridge Nutraceuticals A9270

(19)

Glutamine Immune Deficiency Formula Cam bridge Nutraceuticals A9270

Glutamine Unsweetened Regular Cambridge Nutraceuticals A9270

Glutasorb Hormel Health Labs III B4153

Glytrol Nestle Clinical Nutrition IV B4154

Hearty Balance Elan/Hechems I B4150

Hepatic-Aid McGraw IV B4154

Hi ProCal Diamond Crystal Specialty Foods V B4155

Immun-Aid McGraw IV B4154

Immunocal Immunotec Research V B4155

Impact Novartis Nutrition IV B4154

Impact 1.5 Novartis Nutrition IV B4154

IMPACT Glutamine Novartis Nutrition IV B4154

Impact with Fiber Novartis Nutrition IV B4154

IntensiCal Ready-to-Hang Mead Johnson III B4153

Introlite Ross Labs I B4150

Isocal Mead Johnson I B4150

Isocal HN Mead Johnson I B4150

Isocal HN Plus Mead Johnson I B4150

Isocal II Mead Johnson I B4150

Isofiber Fresenius Medical I B4150

Isolan Elan/Hechems I B4150

Isomil Ross Labs I B4150

Isomil DF Ross Labs I B4150

Isosource Novartis Nutrition I B4150

Isosource 1.5 Novartis Nutrition II B4152

Isosource HN Novartis Nutrition I B4150

Isosource VHN Novartis Nutrition IV B4154

Isotein Novartis Nutrition III B4153

Isotera Isotonic Fresenius Medical II B4152

Jevity Ross Labs I B4150

Jevity Plus Ross Labs I B4150

Jevity RTH Ross Labs I B4150

Juven with HMB MTI BioTech, Inc. A9270

Ketocal SHS I B4151

Kindercal Mead Johnson VI B4156

Kindercal Lacto Free Mead Johnson I B4151

Kindercal TF Mead Johnson VI B4156

Kindercal TF with Fiber Mead Johnson III B4153

Kindercal with Fiber Mead Johnson III B4153

L-Emental Hormel Health Labs III B4153

L-Emental Hepatic Hormel Health Labs IV B4154

L-Emental Pediatric Hormel Health Labs V B4155

L-Emental Plus Hormel Health Labs IV B4154

Lipisorb Mead Johnson IV B4154

Lofenolac Ross Labs IV B4154

Magnacal Mead Johnson II B4152

Magnacal Renal Mead Johnson IV B4154

(20)

Maxamaid Formulas XP Maxamaid MSUD Maxamaid XPHEN, TYR Maxamaid XMTVI Maxamaid XMET Maxamaid XLYS, TRY Maxamaid XLEU Maxamaid

SHS IV B4154

Maxamum Formulas XP Maxamum MSUD Maxamum XMTVI Maxamum XMET Maxamum XLYS, TRY Maxamum XLEU Maxamum

SHS IV B4154

MCT Oil Mead Johns on V X4155

Med Pass 2.0 Diamond Crystal Specialty Foods A9270

Med Plus 2.0 Diamond Crystal Specialty Foods A9270

Meritene Novartis Nutrition I B4150

Microlipid Mead Johnson V X4155

Moducal Mead Johnson V X4155

Modulen IBD Nestle Clinical Nutrition IV B4154

Naturite UniSource I B4150

Naturite Plus UniSource II B4152

Neocate Infant Formula SHS V B4155

Neocate Junior SHS V B4155

Neocate One + Liquid SHS V B4155

Neocate One + Powder SHS V B4155

Nepro Ross Labs IV B4154

Nestle Good Start Nestle Clinical Nutrition I B4150

Newtrition (Flavors) Elan I B4150

Newtrition 1.5 Elan II B4152

Newtrition HN Elan I B4150

Newtrition Isofiber Elan I B4150

Newtrition Isotonic Elan I B4150

Next Step Carnation I B4150

Next Step Soy Carnation I B4150

Nitrolan (Nitro-Pro) Hormel Health Labs I B4150

Nitro-Pro (Nitrolan) Hormel Health Labs I B4150

Novasource 2.0 Novartis Nutrition II B4152

NovaSource Pulmonary Novartis Nutrition II B4152

Novasource Renal Novartis Nutrition IV B4154

NuBasics Nestle Clinical Nutrition I B4150

NuBasics 2.0 Complete Nestle Clinical Nutrition II B4152

NuBasics Plus Nestle Clinical Nutrition II B4152

NuBasics VHP and NuBasics with Fiber Nestle Clinical Nutrition I B4150

NuBasics Juice Drink Nestle Clinical Nutrition V X4155

Nursoy Wyeth-Ayerst Labs I B4150

(21)

Nutramigen Mead Johnson V B4155

Nutramine Calwood Nutritionals Inc. A9270

Nutramine T Calwood Nutritionals Inc. A9270

Nutrapak I B4150

Nutren 1.0 Nestle Clinical Nutrition I B4150

Nutren 1.0 with Fiber Nestle Clinical Nutrition I B4150

Nutren 1.5 Nestle Clinical Nutrition II B4152

Nutren 2.0 Nestle Clinical Nutrition II B4152

Nutren Junior Nestle Clinical Nutrition VI B4156

Nutren Junior with Fiber Nestle Clinical Nutrition III B4153

Nutren VHP Nes tle Clinical Nutrition I B4150

NutriAssist 1.5 Chronimed II B4152

Nutri-Drink Furman Foods I B4150

Nurti-Drink Plus Furman Foods II B4152

Nutiflavor Nyer Nutritional Sys. A9270

NutriHep Nestle Clinical Nutrition IV B4154

Nutrilan Nestle Clinical Nutrition I B4150

NutriMod Protein Supplement Go2 Pharmacy, Inc. V B4155

NutriRenal Nestle Clinical Nutrition IV B4154

Nutrition Nutrition Medical I B4150

Nutrition Plus Nutrition Medical II B4152

Nutrivent Nestle Clinical Nutrition IV B4154

Optimental Ross Labs III B4153

Original New Orleans Smoothee ONOS Company A9270

Osmolite Ross Labs I B4150

Osmolite HN Ross Labs I B4150

Osmolite HN Plus Ross Labs I B4150

Oxepa Ross Labs IV B4154

Pedialyte Ross Labs V X4155

Pediasure Ross Labs VI B4156

Pedisure with Fiber Ross Labs III B4153

Pepdite One + SHS III B4153

Peptamen Nestle Clinical Nutrition V B4155

Peptamen 1.5 Nestle Clinical Nutrition V B4155

Peptamen VHP Nestle Clinical Nutrition IV B4154

Peptamen Junior Nestle Clinical Nutrition V B4155

Peptical Chronimed III B4153

Perative Ross Labs IV B4154

Periflex SHS IV B4154

Phenex 1 and 2 Ross Labs IV B4154

Phenyl-Free 2HP Mead Johnson IV B4154

Phenyl Free Powder Ross Labs IV B4154

Phenylade Applied Nutrition V B4155

Phenylade Amino Acid Applied Nutrition V B4155

Phenylade Bars Applied Nutrition IV B4154

Phenylade Bars Renal Cal Applied Nutrition IV B4154

Phlexy-10 Bars SHS A9270

(22)

Phlexy-10 Capsules SHS A9270

Phlexy-10 Drink Mix SHS V B4155

Phlexy-Vits SHS A9270

Polycose Ross Labs V X4155

Portagen Mead Johnson V B4155

Precision HN Novartis Nutrition III B4153

Precision Isotera Novartis Nutrition III B4153

Precision LR Powder Novartis Nutrition VI B4156

Pregestimil Mead Johnson V B4155

ProBalance Nestle Clinical Nutrition I B4150

Procare National Nutrition V B4155

ProCell Protein Supplement Global Unlimited V B4155

Promix Corpak V B4155

ProMod Ross Labs V X4155

Promote Ross Labs I B4150

Promote with Fiber Ross Labs I B4150

Propac Sherwood Medical V X4155

Propac Plus Sherwood Medical V X4155

ProPass Protein Supplement Hormel Health Labs V B4155

Pro-Peptide Hormel Health Labs IV B4154

Pro-Peptide for Kids Hormel Health Labs V B4155

Pro-Petide VHN Hormel Health Labs IV B4154

Prophree Ross Labs V B4155

ProSobee Mead Johnson I B4150

ProSource Protein Supplement National Nutrition V B4155

Protain XL Mead Johnson IV B4154

ProtoRand Nutritional Supplement Randall, Inc. A9270

Provide Fresenius Medical IV B4154

Pulmocare Ross Labs IV B4154

RCF (Ross Carbohydrate Free) Ross Labs V B4155

Reabilan Nestle Clinical Nutrition III B4153

Reabilan HN Nestle Clinical Nutrition IV B4154

Renalcal Nestle Clinical Nutrition IV B4154

Replete Nestle Clinical Nutrition IV B4154

Re/Neph Ross Labs IV B4154

Replete with Fiber Nestle Clinical Nutrition IV B4154

ReSource Novartis Nutrition I B4150

ReSource Arginaid Novartis Nutrition V B4155

Resource Benefiber Novartis Nutrition V B4155

Resource Diabetic Novartis Nutrition I B4150

Resource Just For Kids Novartis Nutrition VI B4156

Resource Fruit Beverage Novartis Nutrition V X4155

ReSource GlutaSolve Novartis Nutrition V B4155

ReSource Instant Protein Powder Novartis Nutrition V X4155

ReSource Just For Kids with Fiber Novartis Nutrition III B4153

ReSource Plus Novartis Nutrition II B4152

Resource Thickened Juice Novartis Nutrition V X4155

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Resource Thicken-up Novartis Nutrition V X4155

Respalor Mead Johnson II B4152

Restore-X Cambridge Nutraceuticals V B4155

SandoSource Peptide Novartis Nutrition IV B4154

Scandishake Scandipharm I B4150

Similac Neosure Ross Labs I B4150

Similac with Iron Ross Labs I B4150

SLD Ross Labs IV B4154

SoyPro ND Labs V B4155

Stresstein Novartis Nutrition IV B4154

Subdue Mead Johnson III B4153

Subdue Plus Mead Johnson III B4153

Subdue Ready-to-Hang Mead Johnson III B4153

Sumacal Sherwood Medical V B4155

Suplena (Replena) Ross Labs IV B4154

Susta II Mead Johnson I B4150

Sustacal Mead Johnson I B4150

Sustacal Basic Mead Johnson I B4150

Sustacal Fiber Mead Johnson I B4150

Sustacal HC Mead Johnson II B4152

Sustacal Plus Mead Johnson II B4152

Sysco Classic Lactose Free ProCal Diamond Crystal Specialty Foods V B4155

Thick-it Millani V X4155

Tolerex Novartis Nutrition V B4155

Traum Aid McGraw IV B4154

Traumacal Mead Johnson IV B4154

Travasorb Hepatic Nestle Clinical Nutrition IV B4154

Travasorb HN Nestle Clinical Nutrition III B4153

Travasorb MCT Nestle Clinical Nutrition IV B4154

Travasorb Renal Nestle Clinical Nutrition IV B4154

Travasorb STD Powder Nestle Clinical Nutrition VI B4156

Twocal HN Ross Labs II B4152

Ultracal Mead Johnson I B4150

Ultracal HN Plus Mead Johnson I B4150

Ultralan Elan/Hechems II B4152

Vital HN Ross Labs III B4153

Vivonex HN Novartis Nutrition III B4153

Vivonex Pediatric Novartis Nutrition V B4155

Vivonex Plus Novartis Nutrition V B4155

Vivonex T.E.N. Novartis Nutrition IV B4154