Durable Medical Equipment
Please read this important announcement regarding authorizations of durable medical equipment for
Community Health Center Network (CHCN) members enrolled with Anthem Blue Cross Medi-Cal
managed care.
CHCN is pleased to announce that effective October 1, 2015 that CHCN modified its Medi-Cal managed
care contract with Anthem Blue Cross to take on financial responsibility for durable medical equipment
(DME). CHCN selected California Home Medical Equipment (CHME) to be the exclusive vendor for
DME services. See page 2 for an overview of medical equipment provided by CHME and detailed
information by service code can be found on page 4. Contact information for CHME is on page 3.
Effective October 1, 2015, all authorizations for new and continuing durable medical equipment for CHCN
members enrolled in Anthem Blue Cross should be faxed to CHME using the new CHME prior
authorization form which can be found on the CHCN provider portal, also linked below. The form is
electronically fillable and CHME’s fax information is located at the top of the form. CHME will review
and approve authorization requests. For service requests that do not meet medical criteria, CHME will
forward to CHCN for final decision. CHCN’s Utilization Management Department will issue denial letters.
Starting September 1, 2015, CHME began outreaching directly to CHCN members enrolled in Anthem
Blue Cross to transition equipment and supplies from existing authorizations. CHME will work directly
with each member’s current durable medical equipment provider to transition existing services and
equipment to CHME. CHCN is working closely with CHME to ensure a seamless transition and continual
care for all members.
Prior Authorization Form:
https://connect.chcnetwork.org/Portals/0/CHME-CHCN_PriorAuthRequestForm_DME.pdf
Page 1 of 11
Durable Medical Equipment
Examples of durable medical equipment and services provided by CHME:
Durable Medical Equipment:
Hospital Beds
Wheelchairs
Walkers, Seating, Crutches, Canes
Breast Pumps
Bath Equipment
Medical Supplies:
Incontinence Products / Supplies
Ostomy Supplies
Wound Care Supplies
Urologicals /Catheters
Support Stockings
Specialty Rehabilitation Equipment:
Power Wheel Chairs
Mobility Devices
Custom Rehab
Enteral Nutrition:
Tube Feeding Formula
Tube Feeding Supplies/Pumps
Evaluations by Registered
Respiratory:
Home Oxygen Systems/Oximetry
C-PAP/Bi-PAP
Ventilators/Vent Management
Dietitians Nebulizers and Related Supplies
Examples of equipment and supplies not changing and not a part of the CHME contract:
Air Fluidized Beds
Bili-Blanket/Bili-bed
Bone Growth Stimulators
Cold Therapy Units
Custom Compression Hosiery
Continuous Glucose Monitor
CPM Machines
Cranial Helmets
Diabetic Testing & Supplies
Dynamic Splint
Electric Seat Lift Chairs
Hearing aids
High Frequency Compression Vests
Home Infusion Therapy
Insulin Pumps
Mastectomy Related Accessories
Nursing Visits
Ocular Prosthetics
Orthotics & Prosthetics (custom)
Speech Generating Devices
System Electric
Vest Airway Clearance
Page 2 of 11
Durable Medical Equipment
CHME Contact Information:
Email orders
Questions
aaorders@chme.org
aaquestions@chme.org
CHME Phone Number and Options for Patients and Providers: 1-800-906-0626 (toll free)
Option 1
Customer Service
Option 2
Respiratory
customerservice@chme.org
Primary fax: 1-844-583-4049
Alternate fax: 1-650-931-8928
Alternate fax: 1-650-357-8551
respiratory@chme.org
Option 3
Distribution
distribution@chme.org
Option 4
Rehab
Option 8
Medical Supplies
Option 9
Language Line
accepts all orders
other than rehab
and medical
supplies
coordinates
deliveries and
can assist with an
ETA if needed
rehab@chme.org
power and
Fax: 1-650-931-8933
custom manual
wheelchairs,
along with any
rehab type
product
medicalsupplies@chme.org
only takes orders
for incontinence,
medical, ostomy,
urological,
enteral, wound
supplies
CHME offers free interpreter services
CHME Contact Information for Urgent Matters:
Customer Service Supervisor
Medical Supplies Supervisor
Respiratory Therapy Supervisor
Rehab Manager
Distribution Manager
Dispatch
Judy Atienza
Michael Chin
Jan Melendrez
Jan Demuth
Washington Ameperosa
Walter Mendoza
1-800-906-0626 x 222
1-800-906-0626 x 231
1-800-906-0626 x 223
1-650-931-8728 (Direct)
1-800-906-0626 x 234
1-800-906-0626 x 233
CHME Hours of Operation:
Monday through Friday 8:30 to 5:00 pm
Answering service available daily after 5:00 pm and on Friday until the following business day.
Page 3 of 11
DME Services Covered by CHME
Effective 10/01/2015 for CHCN Medi-Cal Members Enrolled with Anthem Blue Cross DME CATEGORY
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Ambulatory Aids
Breast Pumps
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Commodes And Bath Aids
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Cpap/Bipap And Supplies
Decubitus Care Equipment
Decubitus Care Equipment
Decubitus Care Equipment
Decubitus Care Equipment
Decubitus Care Equipment
Decubitus Care Equipment
Enteral
Enteral
Enteral
Enteral
Enteral
Enteral
Enteral
Enteral
Enteral
Enteral
Enteral
Enteral
Enteral
HCPC
E0100
E0105
E0110
E0114
E0116
E0135
E0141
E0143
E0144
E0147
E0148
E0149
E0154
E0155
E0156
E0158
E0159
E0603
E0163
E0165
E0168
E0240
E0241
E0243
E0244
E0245
E0246
E0247
E0248
A7027
A7028
A7029
A7030
A7031
A7032
A7033
A7034
A7035
A7036
A7037
A7038
A7039
A7046
E0470
E0471
E0562
E0601
A4604
E0181
E0185
E0196
E0197
E0199
E0277
B4034
B4035
B4036
B4082
B4087
B4088
B4149
B4150
B4152
B4153
B4154
B4155
B4160
HCPC DESCRIPTION
CANES OF ALL MATRLS-ADJUST OR FIX W/TIP
3 OR 4 PRNG CANE:ANY MTRL-ADJ/FIX W/TIP
CRUTCHES: FOREARM: INCLUDES CRUTCH
CRUTCHES UNDERARM: ALUMINUM: ADJUS
UNDARM CRTCH:ALM:ADJ/FX W/PAD:TIP:HNDGRP
WALKER-FOLDING(PICKUP) ADJUST OR FIXED
WALKER RIGID WHEELED ADJUSTABLE OR FIXED HEIGHT
WALKER FOLDING WHEELED ADJUSTABLE/FIXED HEIGHT
WALKER ENCLOSED 4 SIDED FRAME WHEELD W/POST SEAT
WALKER HEAVY DUTY MX BRAKE SYS VARIBLE WHL RSIST
WALKER HD WO WHEELS RIGID/FLDG
WALKER HEAVY DUTY WHEELED RIGID/FOLD ANY TYPE EA
PLATFORM ATTACHMENT: WALKER: EACH
WHEEL ATTACHMENT: RIGID PICK-UP WA
SEAT ATTACHMENT: WALKER
LEG EXTENSIONS FOR A WALKER
BRAKE ATTACHMENT FOR WHEELED WALKER
BREAST PUMP; DUAL ELECTRIC
COMMODE CHAIR: STATIONARY: WITH FI
COMMODE CHAIR: STATIONARY: WITH DE
COMMODE CHAIR XWD &/OR HD W/WO ARMS
BATH/SHOWER CHAIR W/WO BACK
BATH TUB WALL RAIL: EACH
TOILET RAIL: EACH
RAISED TOILET SEAT
TUB STOOL OR BENCH
TRANSFER TUB RAIL ATTACHMENT
TRANSFER BENCH TUB W/WO COMMODE OPENING
TRNSF BENCH HEVY DUTY TUB W/WO COMMODE OP
COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS
ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPL
NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REP
FULL FACE MASK USED W/POS ARWAY PRESS DEVICE EA
FACE MASK INTERFACE REPLCMT FULL FACE MASK EA
REPLACEMENT CUSHN NASAL APPLICATION DEVICE EACH
REPLACEMENT PILLOWS NASL APPLICATION DEVICE PAIR
NASL INTRFCE POS ARWAY PRSS DEVC W/WO HEAD STRAP
HEADGEAR USED W/POSITIVE AIRWAY PRESSURE DEVICE
CHINSTRAP USED W/POSITIVE AIRWAY PRESSURE DEVICE
TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE
FILTER DISPBL USED W/POS ARWAY PRESSURE DEVICE
FILTER NON DISPBL USED W/POS ARWAY PRESS DEVICE
WATR CHAMB HUMDIFIR USED W/POS ARWAY PRSS DEVC R
RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/O BACKU
RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACK-UP
HUMDIFIR HEATED USED W/POS ARWAY PRESSURE DEVICE
CONTINUOUS AIRWAY PRESSURE (CPAP)
TUBING W/INTGR HEAT ELEM W/POS AIRWAY PRESS DEVC
PRESSURE PAD: ALTER WITH PUMP: HVY DUTY
GEL PRESSURE PAD FOR MATTRESS
GEL PRESSURE MATTRESS
AIR PRESSURE PAD FOR MATTRESS
DRY PRESSURE PAD FOR MATTRESS
ALTERNATING PRESSURE MATTRESS
ENTERAL FEEDING SUPPLY KIT; SYRING
ENTERAL FEEDING SUPPLY KIT; PUMP F
ENTERAL FEEDING SUPPLY KIT; GRAVIT
NASOGASTRIC TUBING WITHOUT STYLET
GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD, ANY MATERI
GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANY MAT
Enteral formula, blenderized natural foods with in
ENTERAL FORMULAE; CATEGORY I; SEMI
ENTERAL FORMULAE; CATEGORY II: INT
ENTERAL FORMULAE; CATEGORY III: HY
ENTERAL FORMULAE; CATEGORY IV: DEF
ENTERAL FORMULAE; CATEGORY V: MODU
Enteral formula, for pediatrics, nutritionally com
Page 4 of 11 DME Services Covered by CHME
Effective 10/01/2015 for CHCN Medi-Cal Members Enrolled with Anthem Blue Cross Enteral
Enteral
Enteral
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Hospital Beds
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Incontinence Supplies
Lymphedema Products
Lymphedema Products
Lymphedema Products
Lymphedema Products
Lymphedema Products
Lymphedema Products
Lymphedema Products
Lymphedema Products
Lymphedema Products
Lymphedema Products
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Manual Wheelchairs
Misc. Respiratory
Misc. Respiratory
Monitoring Equipment
Monitoring Equipment
Monitoring Equipment
B4161
B9002
E0776
E0271
E0272
E0292
E0295
E0297
E0301
E0302
E0303
E0304
E0305
E0310
E0372
E0705
E0910
E0911
E0912
E0940
T4521
T4522
T4523
T4524
T4525
T4526
T4527
T4528
T4530
T4531
T4532
T4533
T4534
T4535
T4536
T4537
T4541
T4542
E0651
E0652
E0656
E0667
E0668
E0669
E0670
E0673
E0675
E0676
E1038
E1225
E1226
E2601
E2602
E2611
K0001
K0002
K0003
K0004
K0006
K0007
K0195
E0202
E0481
A4556
A4557
E0618
Enteral formula, for pediatrics, hydrolyzed/amino
ENTERAL NUTRITION INFUSION PUMP IV POLE
MATTRESS: INNERSPRING
MATTRESS: FOAM RUBBER
HOSPITAL BED: VARIABLE HEIGHT: HIHOSPITAL BED:SEMI-ELECTRIC (HEAD A
HOSPITAL BED: TOTAL ELECTRIC (HEAD
HOS BED HEVY DUTY XTRA WIDE W/WT CAPACTY > 350 P
HOS BED XTRA HEVY DUTY XTRA WIDE W/WT CAPACTY >
HOS BED HEVY DUTY XTRA WIDE W/WT CAPACTY > 350 P
HOS BED XTRA HEVY DUTY XTRA WIDE W/WT CAPACTY >
BED SIDE RAILS: HALF LENGTH
BED SIDE RAILS: FULL LENGTH
POWERED AIR MATTRESS OVERLAY DAILY RENT
TRANSFER BOARD OR DEVICE ANY TYPE EACH
TRAP BAR:A/K/A PT HLPR ATT TO BED: W/BAR
TRAPEZ BAR HEVY DUTY PT WT >250 LBS BED GRAB BAR
TRAPEZ BAR HEVY DUTY PT WT > 250 LBS FREE STAND
TRAP BAR:FREE STANDING: COMP W/GRAB BAR
Adult sized disposable incontinence product, brief
Adult sized disposable incontinence product, brief
Adult sized disposable incontinence product, brief
Adult sized disposable incontinence product, brief
Adult sized disposable incontinence product, prote
Adult sized disposable incontinence product, prote
Adult sized disposable incontinence product, prote
Adult sized disposable incontinence product, prote
Pediatric sized disposable incontinence product, b
Pediatric sized disposable incontinence product, p
Pediatric sized disposable incontinence product, p
Youth sized disposable incontinence product, brief
Youth sized disposable incontinence product, prote
Disposable liner/shield/guard/pad/undergarment, fo
Incontinence product, protective underwear/pull-on
Incontinence product, protective underpad, reusabl
Incontinence product, disposable underpad, large,
Incontinence product, disposable underpad, small s
PNEUMATIC COMPRESSOR: SEGMENTAL HO
PNEUMATIC COMPRESSOR: SEGMENTAL HO
SEG PNEUMAT APPLIANCE USE W/PNEUMAT COMPRS TRUNK
PNEUMATIC APPLIANCE FOR USE WITH S
PNEUMATIC APPLIANCE FOR USE WITH S
SEG PNEUMATIC APPL USE W/PNEU COMPRES
Segment pneumatic appliance w compressor integ 2 f
SEGMENT GRAD PRESS PNEUMATIC APPLIANCE HALF LEG
PNEUMAT COMPRS DEVC HI PRSS RAPID INFLATION/DEFL
INTERMITTENT LIMB COMPRESSION DEVICE NOS
TRANSPORT CHAIR ADULT SIZE
MANUAL WHEELCHAIR ACCESS SEMI-RECLINING BACK EA
MANUAL WHEELCHAIR ACCESS FULLY RECLINING BACK EA
General Use wheelchair seat cushion, width less th
General Use wheelchair seat cushion, width 22 inch
General Use wheelchair back cushion, width less th
STANDARD WHEELCHAIR
STANDARD HEMI (LOW SEAT) WHEELCHAIR
LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH: LIGHTWEIGHT WHEELCHAIR
HEAVY DUTY WHEELCHAIR
EXTRA HEAVY DUTY WHEELCHAIR
ELEVATING LEG REST-PAIR-USED W/RENTED WC BASE
PHOTOTHERAPY (BILIRUBIN) LIGHT WIT
INTRAPULM PERCUSSIVE VENT SYSTEM&REL ACSSORIES
ELECTRODES: (E.G.: APNEA MONITOR)
LEAD WIRES: (E.G.: APNEA MONITOR)
APNEA MONITOR WITHOUT RECORDING FEATURE
Page 5 of 11 DME Services Covered by CHME
Effective 10/01/2015 for CHCN Medi-Cal Members Enrolled with Anthem Blue Cross Monitoring Equipment
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Nebulizers/Compressors And Supplies
Negative Pressure Wound Therapy
Negative Pressure Wound Therapy
Negative Pressure Wound Therapy
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
E0619
A7003
A7004
A7005
A7007
A7010
A7012
A7013
A7015
A7016
E0565
E0570
E2402
A6550
A7000
A4310
A4313
A4314
A4320
A4322
A4326
A4331
A4332
A4333
A4338
A4340
A4344
A4349
A4351
A4352
A4353
A4357
A4358
A4362
A4363
A4364
A4366
A4367
A4371
A4373
A4376
A4385
A4388
A4389
A4390
A4392
A4394
A4397
A4400
A4402
A4405
A4406
A4407
A4409
A4411
A4413
A4414
A4415
A4416
A4417
A4419
A4424
A4425
A4428
A4430
A4432
APNEA MONITOR WITH RECORDING FEATURE
ADMIN SET W/SMALL VOL NONFLTR PNEUM NEB DISP
SMALL VOL NONFLTR PNEUM NEB DISP
ADMIN SET W/SMALL VOL NONFLTR PNEUM NEB NONDISP
LG VOL NEB DISP UNFILL USED W/AREO COMPRES
CORRG TUBING DISP USED W/LG VOL NEB 100 FEET
WATER COLLEC DEV USED W/ LG VOL NEB
FLTR DISP USED W/ AREO COMPRES
AREO MASK USED W/ DME NEB
DOME/MOUTHPIECE USED W/SMALL VOL US NEB
COMPRESSOR: AIR POWER SOURCE FOR E
NEBULIZER W/ COMPRESSOR
Pump Rental
Dressing Kit
Suction Canister
INSERTION TRAY WITHOUT DRAINAGE BA
INSERTION TRAY WITHOUT DRAINAGE BA
INSERTION TRAY WITH DRAINAGE BAG W
IRRIGATION TRAY WITH BULB OR PISTO
IRRIGATION SYRINGE: BULB OR PISTON
MALE EXT CATH SPCLTY TYPE INTEGRAL CLCT CHAMB EA
EXT DRAIN TUBING W/CNCTR/ADPTR EA
LUBE IND STR PKT-URIN CATH INS EA
URIN CATH ANC DEV ADHES SKIN ATT EA
INDWELLING CATHETER; FOLEY TYPE: T
INDWELLING CATHETER; SPECIALTY TYP
INDWELLING CATHETER: FOLEY TYPE: T
Male external catheter; with or without adhesive;
INTERMITTENT URINARY CATHETER; STR
INTERMITTENT URINARY CATHETER; COU
INTERMITTENT URINARY CATHETER W/INSERTION SUPP
BEDSIDE DRAINAGE BAG: DAY OR NIGHT
URINARY LEG BAG; VINYL: WITH OR WI
SKIN BARRIER; SOLID: 4 X 4 OR EQUI
OSTOMY CLAMP ANY TYPE REPLACEMENT ONLY EACH
ADHESIVE FOR OSTOMY OR CATHETER; L
OSTOMY VENT ANY TYPE EACH
OSTOMY BELT
OSTMY SKIN BARR POW PER OZ
OSTMY SKIN BARR W/ FLNG W/CONVEX ANY SZ EA
OSTMY PCH DRNABLE W/ FCPLT ATT RUB EA
OSTMY SKIN BARR SLD EXT WEAR W/O BLT-IN CONVX EA
OSTMY PCH DRNABLE W/EXT WEAR BARR W/O CONVX EA
OSTMY PCH DRNABLE W/STAN WEAR BARR EA
OSTMY PCH DRNABLE W/EXTWEAR/CONVEX EA
OSTMY PCH URIN W/STAN WEAR BARR/CONVEX EA
OSTMY DEODRNT/LIQUID PER FL OZ
IRRIGATION SUPPLY; SLEEVE
OSTOMY IRRIGATION SET
LUBRICANT
OSTOMY SKIN BARRIER NON-PECTIN BASED PASTE-OUNCE
OSTOMY SKIN BARRIER PECTIN-BASED PASTE PER OUNCE
OST SKN BARRIER W/BUILT-IN CONVXITY 4X4 IN/< EA
OST SKN BARR EXT W/O BUILT-IN CONVXTY 4X4 IN/<EA
OST SKN BARRIER SOLID 4X4/EQ W/BUILT-IN CONVXITY
OST POUCH DRNABLE HI OP BARRIER W/FLNGE/FLTR EA
OST SKN BARRIER W/O BUILT-IN CONVXITY 4X4 IN/<EA
OST SKN BARRIER W/O BUILT-IN CONVXITY >4X4 IN EA
OSTOMY POUCH CLOSED W/BARRIER ATTCH W/FILTER EA
OST POUCH CLO W/BARRIER ATTCH W/BUILT-IN CONVXIT
OST POUCH CLOS; BARRIER W/NON-LOCK FLNGE W/FLTR
OSTOMY POUCH DRAINABLE W/BARRIER ATTCH W/FLTR EA
OST POUCH DRNABLE; BARRIER W/NON-LOCK FLNGE W/FL
OST POUCH URIN W/EXT WEAR BARRIER ATTCH W/FAUCET
OST POUCH URIN W/EXT WEAR BARRIER ATTCH W/BUILTOST POUCH URIN; BARRIER W/NON-LOCK FLNGE W/FAUCE
Page 6 of 11 DME Services Covered by CHME
Effective 10/01/2015 for CHCN Medi-Cal Members Enrolled with Anthem Blue Cross Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy And Urological
Ostomy-Urostomy-Ileostomy
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Oxygen Systems & Supplies
Patient Lifts
Patient Lifts
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
A4433
A4450
A4452
A4455
A4456
A4461
A4481
A4483
A4927
A5056
A5057
A5061
A5063
A5102
A5112
A5114
A5120
A5131
A4421
A4615
A4616
E0431
E0434
E0439
E0441
E0442
E0443
E0444
E1353
E1355
E1390
E1392
K0738
E0621
E0630
E0950
E0951
E0955
E0956
E0957
E0960
E0961
E0966
E0967
E0971
E0973
E0978
E0981
E0982
E0990
E0992
E0994
E0995
E1002
E1007
E1008
E1010
E1016
E1017
E1018
E1020
E1028
E1161
E1228
E1232
E1233
OSTOMY POUCH URIN; USE BARRIER W/LOCK FLNGE EA
TAPE NON-WATERPROOF PER 18 SQUARE INCHES
TAPE WATERPROOF PER 18 SQUARE INCHES
ADHESIVE REMOVER OR SOLVENT (FOR T
Adhesive remover wipes any type each
SURGICAL DRESSING HOLDER NON-REUSABLE EACH
TRACHEOSTOMA FILTER ANY TYPE ANY SIZE-EA
MOIST EXCHG DISP USE W/INVASIVE MECH VENT
GLOVES: STERILE OR NON-STERILE: PE
Ostomy pouch drain extend wear barrier attach with
Ostomy pouch drain extend barrier builtin convexit
POUCH: DRAINABLE; WITH BARRIER ATT
POUCH: DRAINABLE; FOR USE ON BARRI
BEDSIDE DRAINAGE BOTTLE: RIGID OR
URINARY LEG BAG; LATEX
LEG STRAP; FOAM OR FABRIC: PER SET
SKIN BARRIER WIPES OR SWABS EACH
APPLIANCE CLEANER: INCONTINENCE AN
OSTOMY SUPPLY; MISCELLANEOUS
CANNULA: NASAL
TUBING (OXYGEN): PER FOOT
PORTABLE GAS OXYGEN SYSTEM - RENTAL
PORTABLE LIQUID OXYGEN SYSTEM - RENTAL
STATIONARY LIQ OXYGEN SYSTEM: RENTAL
OXYGEN CONTENTS: GASEOUS: PER UNIT
OXYGEN CONTENTS: LIQ PER UNIT (1U=10LBS)
PORTABLE OXYGEN CONTENTS GASEOUS / UNIT
PORTABLE OXYGEN CONTENTS LIQ PER UNIT
REGULATOR
STAND/RACK
O2 CONC 1 DEL PORT DEL 85 %/> CONC@PRSC FLW RATE
PORTABLE OXYGEN CONCENTRATOR RENTAL
PORTABLE GASEOUS O2 SYS RENTAL; HOME COMPRESSOR
SLING OR SEAT: PATIENT LIFT: CANVA
PATIENT LIFT: HYDRAULIC: WITH SEAT/SLING
WHEELCHAIR ACCESSORY TRAY EACH
HEEL LOOP/HOLDER WITH OR WITHOUT ANKLE STRAP EA
WC ACSS HEADREST CUSHNED PRFAB W/FIX MOUNTING HA
WC ACSS LAT TRNK/HIP SUPP PRFAB W/FIX MOUNTING H
WC ACSS MED THI SUPP PRFAB W/FIX MOUNTING HARDWA
WC ACSS SHLDR HRNSS/STRAPS/CHST STRAP W/TYPE MOU
MANUAL WHEELCHAIR ACCESS WHEEL LOCK BRAKE EXT EA
MANUAL WHEELCHAIR ACCESS HEADREST EXTENSION EA
MANUAL WHEELCHAIR ACCESS HAND RIM W/PROJ EA
BACK OF CHAIR - ANTI-TIPPING DEVICE
WC ACCSS ADJUSTBL HT DTACH ARMRST CMPL ASSMBL EA
WHEELCHAIR ACCESSORY SAFETY BELT/PELVIC STRAP EA
WHEELCHAIR ACCESS SEAT UPHLSTR REPLCMT ONLY EA
WHEELCHAIR ACCESS BACK UPHLSTR REPLCMT ONLY EA
WHEELCHAIR ACCESS ELEV LEG REST CMPL ASSMBL EA
MANUAL WHEELCHAIR ACCESSORY SOLID SEAT INSERT
ARM REST: EACH
WHEELCHAIR ACCESSORY CALF REST/PAD EACH
WHEELCHAIR ACCESS POWER SEATING SYSTEM TILT ONLY
WC ACSS PWR SEATING SYS COMB TILT&RECLINE W/MECH
WC ACSS PWR SEATING SYS COMB TILT&RECLINE W/PWR
WC ACSS ADD PWR SEATING SYS PWR LEG ELEV SYS W/L
SHOCK ABSORBER FOR POWER WHEELCHAIR EACH
HEVY DUTY SHOCK ABSORBR HEVY/XTRA HEVY MNL WC EA
HEVY DUTY SHOCK ABSORBR HEVY/XTRA HEVY PWR WC EA
RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR
WC ACSS MNL SWINGAWAY RETRACTABLE/REMV MOUNTING
MANUAL ADULT SIZE WHEELCHAIR INCLUDES TILT SPACE
BACK OF CHAIR - SPECIAL BACK HEIGHT
WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/SEAT SYS
WC PED SZ TILT-IN-SPACE RIGD ADJUSTBL W/O SEAT
Page 7 of 11 DME Services Covered by CHME
Effective 10/01/2015 for CHCN Medi-Cal Members Enrolled with Anthem Blue Cross Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
E1234
E1236
E1296
E1298
E2201
E2202
E2203
E2204
E2205
E2206
E2207
E2208
E2209
E2210
E2211
E2212
E2213
E2214
E2217
E2218
E2220
E2221
E2222
E2224
E2226
E2227
E2231
E2300
E2310
E2311
E2313
E2321
E2323
E2328
E2329
E2330
E2340
E2341
E2359
E2361
E2362
E2363
E2364
E2365
E2366
E2367
E2368
E2370
E2373
E2374
E2375
E2376
E2377
E2381
E2382
E2383
E2384
E2385
E2386
E2387
E2388
E2391
E2392
E2394
E2395
E2396
WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/O SEAT
WHLCHAIR PED SIZE FOLD ADJUSTBL W/SEATING SYSTEM
SPECAL WHEELCHAIR SEAT HEIGHT FROM FLOOR
SPEC WHLCHR ST DEPTH &/OR WIDTH BY CONST
MNL WC ACSS NONSTD SEAT FRME WDTH >/= 20 IN&< 24
MANUAL WC ACSS NONSTD SEAT FRME WIDTH 24-27 IN
MANUAL WC ACSS NONSTD SEAT FRME DEPTH 20 < 22 IN
MANUAL WC ACSS NONSTD SEAT FRME DEPTH 22 25 IN
Manual wheelchair accessory, handrim without proje
Manual wheelchair accessory, wheel Lock assembly,
WHEELCHAIR ACCESSORY CRUTCH AND CANE HOLDER EACH
WHEELCHAIR ACCESSORY CYLINDER TANK CARRIER EACH
WHEELCHAIR ACCESSORY ARM TROUGH EACH
WHEELCHAIR ACCESS BEARINGS ANY TYPE REPL ONLY EA
MNL WHLCHAIR ACSS PNEUMAT PROPULSION TIRE ANY SZ
MNL WC ACESS TUBE PNEUMAT PROPULSION TIRE ANY SZ
MNL WC ACSS INSRT PNEUMAT PROPULSION TIRE ANY SZ
MNL WHLCHAIR ACCESS PNEUMAT CASTER TIRE ANY SIZE
MNL WHLCHAIR ACCSS FOAM FILL CASTR TIRE ANY SIZE
MNL WHLCHAIR ACCSS FOAM PROPULSION TIRE ANY SIZE
MNL WHLCHAIR ACESS SOLID PROPULSION TIRE ANY SZ
MNL WHEELCHAIR ACESS SOLID CASTER TIRE ANY SZ EA
MNL WC ACSS SOLID CASTR TIRE INTGR WHL ANY SZ EA
MNL WC ACESS PROPULSION WHL EXCLD TIRE ANY SZ EA
MNL WHLCHAIR ACSS CASTR FORK ANY SZ REPL ONLY EA
MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE
MNL WC ACCESS SOLID SEAT SUPP BASE INCL HARDWARE
POWER WHEELCHAIR ACCESS POWER SEAT ELEV SYSTEM
PWR WC ACSS ELEC CNCT BETWN WC CNTRLLER&ONE PWR
PWR WC ACSS ELEC CNCT BETWN WC CNTRLLER&TWO/MORE
POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO
PWR WC ACSS HND CNTRL INTERFCE REMOTE JOYSTICK N
PWR WC ACSS SPCLTY JOYSTICK HNDLE HND CNTRL INTE
PWR WC ACSS HEAD CNTRL/EXT CNTRL INTERFCE ELEC P
PWR WC ACSS HEAD CNTRL INTERFCE CNTC SWTCH MECH
PWR WC ACSS HEAD CNTRL INTERFCE PROXIMITY SWTCH
PWR WC ACSS NONSTD SEAT FRME WIDTH 20-23 IN
PWR WC ACSS NONSTD SEAT FRME WIDTH 24-27 IN
Power wheelchair group 34 sealed battery ea gel ce
PWR WC ACSS 22NF SEALED LEAD ACID BATTRY EA
PWR WC ACSS GRP 24 NON-SEALED LEAD ACID BATTRY E
PWR WC ACSS GRP 24 SEALED LEAD ACID BATTRY EA
PWR WC ACSS U-1 NON-SEALED LEAD ACID BATTRY EA
PWR WHLCHAIR ACSS U-1 SEALED LEAD ACID BATTRY EA
PWR WC ACSS BATTRY CHRGR 1 MODE W/ONLY 1 BATTRY
PWR WC ACSS BATTRY CHRGR DUL MODE W/EITHER BATTR
Power wheelchair component, motor, replacement onl
Power wheelchair component, motor and gear box com
PWR WC MINI-PROPORTIONAL COMPACT REMOTE JOYSTICK
PWR WC STANDARD REMOTE JOYSTICK REPLACEMENT ONLY
PWR WC NONEXPNDABLE CONTROLLER REPLACEMENT ONLY
PWR WC EXPANDABLE CONTROLLER REPLACEMENT ONLY
PWR WC EXPANDABLE CONTROLLER UPGRADE INIT ISSUE
PWR WC PNEUMATIC DRIVE WHEEL TIRE REPL ONLY EACH
PWR WC TUBE PNEUMATIC DRIVE WHEEL TIRE REPL EACH
PWR WC INSERT PNEUMATIC WHEEL TIRE REPL ONLY EA
PWR WC PNEUMATIC CASTER TIRE REPL ONLY EACH
PWR WC TUBE PNEUMATIC CASTER TIRE REPL ONLY EACH
PWR WC FOAM FILLED DRIVE WHEEL TIRE REPL ONLY EA
PWR WC FOAM FILLED CASTER TIRE REPL ONLY EACH
PWR WC FOAM DRIVE WHEEL TIRE REPL ONLY EACH
PWR WC SOLID CASTER TIRE REPLACEMENT ONLY EACH
PWR WC SOLID CASTER TIRE INTEGRTED WHEEL REPL EA
PWR WC DRIVE WHEEL EXCLUDES TIRE REPL ONLY EACH
PWR WC CASTER WHEEL EXCLUDES TIRE REPL ONLY EACH
PWR WC CASTER FORK REPLACEMENT ONLY EACH
Page 8 of 11 DME Services Covered by CHME
Effective 10/01/2015 for CHCN Medi-Cal Members Enrolled with Anthem Blue Cross Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
E2603
E2604
E2605
E2606
E2607
E2608
E2609
E2613
E2614
E2615
E2616
E2617
E2619
E2620
E2621
E2622
E2623
E2624
E2625
E8000
K0005
K0015
K0017
K0019
K0020
K0037
K0038
K0040
K0041
K0042
K0043
K0044
K0045
K0046
K0047
K0050
K0051
K0052
K0053
K0056
K0069
K0070
K0072
K0077
K0108
K0462
K0669
K0733
K0739
K0800
K0801
K0802
K0806
K0807
K0808
K0822
K0823
K0824
K0825
K0826
K0827
K0848
K0849
K0850
K0856
K0860
Skin protection wheelchair seat cushion, width les
Skin protection wheelchair seat cushion, width 22
Positioning wheelchair seat cushion, width less th
Positioning wheelchair seat cushion, width 22 inch
Skin protection and positioning wheelchair seat cu
Skin protection and positioning wheelchair seat cu
Custom fabricated wheelchair seat cushion, any siz
Positioning wheelchair back cushion, posterior, wi
Positioning wheelchair back cushion, posterior, wi
Positioning wheelchair back cushion, posterior-lat
Positioning wheelchair back cushion, posterior-lat
Custom fabricated wheelchair back cushion, any siz
Replacement cover for wheelchair seat cushion or b
Positioning wheelchair back cushion, planar back w
Positioning wheelchair back cushion, planar back w
SKIN PROTECT WC SEAT CUSH WIDTH <22 IN ANY DEPTH
SKIN PROTCT WC SEAT CUSH WIDTH 22 IN/> ANY DEPTH
SKIN PROTECT & POSITIONING WC CUSH WIDTH < 22 IN
SKIN PROTECT & POSITIONING WC CUSH WIDTH 22 IN/>
Gait trainer, pediatric size, posterior support, i
ULTRALIGHTWEIGHT WHEELCHAIR
DETACH: NON-ADJUST HEIGHT ARMREST: EACH
DETACH:ADJUST HEIGHT ARMREST:BASE:EACH
ARM PAD:EACH
FIXED: ADJUSTABLE HEIGHT ARMREST: PAIR
HIGH MOUNT FLIP-UP FOOTREST: EACH
LEG STRAP: EACH
ADJUSTABLE ANGLE FOOTPLATE: EACH
LARGE SIZE FOOTPLATE: EACH
STANDARD SIZE FOOTPLATE: EACH
FOOTREST: LOWER EXTENSTION TUBE: EACH
FOOTREST: UPPER HANGER BRACKET: EACH
FOOTREST: COMPLETE ASSEMBLY
ELEVATING LEGREST:LOWER EXT TUBE: EACH
ELEVATING LEGREST:UPPER HANGER BRACKET:E
RATCHET ASSEMBLY
CAM RELEASE ASSY:FOOTREST OR LEGREST:EAC
SWINGAWAY:DETACHABLE FOOTREST: EACH
ELEVATING FOOTRESTS:ARTICULATING(TELESCO
SEAT HEIGHT <17 OF < OR = 21 HIGH STRE
REAR WHEEL ASSY:COMP:W/SOLID TIRE:SPOKES
REAR WHEEL:ASSY:COMP:W/PNEUMATIC TIRE:SP
FRONT CASTER ASSY:COMP:W/SEMI-PNEUMATIC
FRONT CASTER ASSY:COMP:W/SOLID TIRE:EACH
OTHER ACCESSORIES
TMP REPLC PT OWN EQUIP BEING REPR/ANY TYPE
Wheelchair seat or back cushion, no written coding
PWR WC 12-24 AMP HR SEALED LEAD ACID BATTERY EA
Repair or nonroutine service for durable medical e
PWR OP VEH GRP 1 STD PT WT CAP TO & INCL 300 LBS
PWR OP VEH GRP 1 HEAVY DUTY PT 301 TO 450 LBS
PWR OP VEH GRP 1 VERY HEAVY DUTY PT 451-600 LBS
PWR OP VEH GRP 2 STD PT WT CAP TO & INCL 300 LBS
PWR OP VEH GRP 2 HEAVY DUTY PT 301 TO 450 LBS
PWR OP VEH GRP 2 VERY HEAVY DUTY PT 451-600 LBS
PWR WC GRP 2 STD SLING SEAT PT TO &=300 LBS
PWR WC GRP 2 STD CAPTAINS CHAIR PT TO &=300 LBS
PWR WC GRP 2 HEVY DUTY SLING SEAT PT 301-450 LBS
PWR WC GRP 2 HEVY DUTY CAPT CHAIR PT 301-450 LBS
PWR WC GRP 2 VRY HVY DTY SLNG SEAT PT 451-600 LB
PWR WC GRP 2 VRY HVY DTY CAPT CHR PT 451-600 LBS
PWR WC GRP 3 STD SLING SEAT PT TO & = 300 LBS
PWR WC GRP 3 STD CAPTAIN CHAIR PT TO & = 300 LBS
PWR WC GRP 3 HVY DUTY SLING SEAT PT 301-450 LBS
PWR WC GRP 3 STD 1 PWR SLING SEAT PT TO &=300 LB
PWR WC GRP 3 V HD 1 PWR SLING SEAT PT 451-600 LB
Page 9 of 11 DME Services Covered by CHME
Effective 10/01/2015 for CHCN Medi-Cal Members Enrolled with Anthem Blue Cross Rehab Equipment
Rehab Equipment
Rehab Equipment
Rehab Equipment
Stimulators
Stimulators
Stimulators
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Suction And Trach Supplies
Ventilators And Misc Rt
Ventilators And Misc Rt
Ventilators And Misc Rt
Ventilators And Misc Rt
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
Wound Care
K0861
K0862
K0868
K0877
A4595
E0720
E0730
A4605
A4623
A4624
A4625
A4628
A4629
A7001
A7002
A7520
A7521
A7525
A7526
A7527
A9276
E0600
A4618
E0450
E0463
E0464
A6021
A6022
A6196
A6197
A6199
A6203
A6207
A6209
A6210
A6212
A6216
A6217
A6219
A6220
A6222
A6223
A6224
A6234
A6235
A6240
A6242
A6248
A6250
A6251
A6252
A6253
A6254
A6257
A6258
A6259
A6260
A6266
A6402
A6403
A6407
A6443
A6446
A6447
A6448
A6449
PWR WC GRP 3 STD MX PWR SLNG SEAT PT TO &=300 LB
PWR WC GRP 3 HD MX PWR SLING SEAT PT 301-450 LBS
PWR WC GRP 4 STD SLING SEAT PT TO & = 300 LBS
PWR WC GRP 4 STD 1 PWR SLING SEAT PT TO &=300 LB
TENS SUPPLIES, 2 LEAD, PER MONTH
TRNSCTNOUS ELEC NRV STIM:2 LD:LOCAL STIM
TRANCUTNOUS ELEC NRV STIM:4 LD MULT STIM
Tracheal suction catheter, closed System, each
TRACHEOSTOMY INNER CANNULA
TRACHEAL SUCTION CATHETER: ANY TYP
TRACHEOSTOMY CARE OR CLEANING STAR
OROPHARYNGEAL SUCTION CATHETER, EACH
TRACH CARE KIT FOR ESTABLISHED TRACHEOSTOMY
CANISTER NON-DISP USED W/SUCT PUMP EA
TUBING USED W/SUCT PUMP EA
TRACHEOST/LARYNGECT TUBE NON-CUFFED POLYVINYLCHL
TRACHEOST/LARYNGECT TUBE CUFFED POLYVINYLCHLORID
TRACHEOSTOMY MASK EACH
TRACHEOSTOMY TUBE COLLAR/HOLDER EACH
Tracheostomy/laryngectomy tube plug/stop, each
SENSOR; INVASIVE (E.G. SUBCUTANEOUS), DISPOSABLE,
SUCTION PUMP: HOME MODEL: PORTABLE
BREATHING CIRCUITS
VOLUME VENTILATOR: STATIONARY OR PORTBLE
Pressure support ventilator with volume control mo
Pressure support ventilator with volume control mo
COLLAGEN DSG PAD SIZE <=16 SQ IN EA
COLL DSG PAD >16SQ IN <= 48SQ IN EA
ALGINATE DSG WOUND CVR PAD <=16 SQ IN-EA
ALGINATE DSG WOUND PAD >16 SQ IN <=48 SQ IN-EA
ALGINATE DSG WOUND FILLER PER 6 IN
COMPOSITE DSG <=16 SQ IN W/ANY ADHES BORD-EA
CONTACT LAYER >16 SQ IN BUT <=48 SQ IN-EA DSG
FOAM DSG WOUND CVR <=16 SQ IN WO ADHES BORDER-EA
FOAM DSG WOUND CVR >16 <=48 SQ IN WO ADHES-EA
FOAM DSG 16 SQ IN OR < W/ANY SZ ADHES BORD-EA
GZE NON-IMPG/STER <=16 SQ IN WO ADHES BORD-EA
GZE NON-IMPG/STER >16 <=48 SQ IN WO ADHES-EA
GZE NON-IMPG <=16 SQ IN W/ANY ADHES BORD-EA
GZE NON-IMP >16 <=48 SQ IN W/ADHES BORD-EA
GZE IMPG NOT H2O/SAL <=16 SQ IN WO ADHES BORD-EA
GZE IMPG NOT H20/SAL >16 <=48 SQ IN WO ADHES-EA
GZE IMPG NOT H2O/SAL >48 SQ IN WO ADHES-EA
HYDRCLLD DSG <=16 SQ IN WO ADHES BORD-EA DSG
HYDRCLLD DSG >16 <= 48 SQ IN WO ADHES BORD-EA
HYDRCLLD DSG WOUND FILLER PASTE-PER FL OZ
HYDROGEL DSG <=16 SQ IN WO ADHES BORDER-EA
HYDROGEL WOUND FILLER GEL-PER FL OZ
SKIN SEALANTS PROTECT MOISTURIZER ANY TYPE/SIZE
SPEC ABSORP DSG <=16 SQ IN WO ADHES BORD-EA
SPEC ABSORP DSG >16 <=48 SQ IN WO ADHES BORD-EA
SPEC ABSORP DSG >48 SQ IN WO ADHES BORD-EA
SPEC ABSORP DSG <=16 SQ IN W/ANY ADHES BORD-EA
TRANSPARENT FILM <=16 SQ IN-EA DSG
TRANSPARENT FILM >16 <=48 SQ IN-EA DSG
TRANSPARENT FILM >48 SQ IN-EA DSG
WOUND CLEANSERS ANY TYPE/SIZE
GAUZE INPRG-NOT H20/SAL-ANY WIDTH PER LINEAR YD
GAUZE NON-IMPREG STER <=16 SQ IN WO ADHES-EA
GAUZE NON-IMPREG STER >16-<=48 SQ IN WO ADHES-EA
PACKING STRIPS NON-IMPREGNTD UP 2 IN WDTH-LINR Y
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN NON-ST
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN STERL
CONFORMING BANDGE NON-ELAST KNITTED/WOVEN STERL
LT COMPRS BANDGE ELAST KNITTED/WOVEN WDTH < 3 IN
LT COMPRS BANDGE ELAST KNITTED/WOVEN WDTH >/= 3
Page 10 of 11 DME Services Covered by CHME
Effective 10/01/2015 for CHCN Medi-Cal Members Enrolled with Anthem Blue Cross Wound Care
Wound Care
Wound Care
A6453
A6454
A6457
SLF-ADHERENT BANDGE ELAST NON-KNITTED/NON-WOVEN
SLF-ADHERENT BANDGE ELAST NON-KNITTED/NON-WOVEN
TUBULAR DRSG W/WO ELASTIC ANY WDTH PER LINEAR YD
Page 11 of 11