Appendix A
DURABLE MEDICAL EQUIPMENT AND SUPPLIES

Covered Supplies Alternating Pressure Point Pads Apnea Monitor Blood Plasma or Whole Blood Bone Growth Stimulators Braces (except dental) Canes and Crutches Casts, Splints, Trusses Compression Garment (inflatable & noninflatable including surgical stockings) Custom Food Orthotics (ordered by DPM, MD, OD only) Electro-Larnyx Glucose Monitor Hospital Beds (manual or electric) Infusion Pumps (enteral or parenteral nutritional therapy only) Intermittent Compression Units Iron Lungs Kidney Hemodialysis Machines Muscle Stimulators (used during therapy) Nasal CPAP Nebulizers Nerve Stimulator Orthotic Devices Ostomy Supplies (for colostomy or ileostomy) Oxygen and Rental Equipment (for the administration of oxygen) Pacemakers Penile Implants Prosthesis, Artificial Limbs or Eyes (except replacement thereof) Radium, Radioactive Isotopes and X-ray Therapy Surgical Bras (post-mastectomy) Surgical Dressing (therapeutic and protective coverings applied to wounds or lesions either on the skin or opening to the skin in connection with a surgical procedure performed by a Surgeon, including: adhesive tape, roll gauze, bandages, and disposable compression material) Therapeutic Mattress Traction Equipment Ultra-Violet Equipment Walkers Wheel chairs

Non-Covered Automatic Blood Pressure Monitor Bathtub or Shower Seat/Bench/Chair Beds/Lounge Biofeedback Equipment Birth Control Devices Blood Pressure Cuff Breast Pumps Cervical Pillow Circulators Colonic Irrigation Units Communication Devices Environmental Equipment including: Air Cleaner, Air Filter, Humidifier, Air Conditioner, Dehumidifier, Precipitator, and Vaporizers Exercise Equipment Exercycle Food Blenders Gravetonical Traction Device Handrails Heating Pads Hot Tubs Hydraulic Lifts Lifts, Transfer Boards/Bench Massage Devices Nocturnal Enuresis Devices Sauna Baths/Sitz Baths Shoe Inserts, Arch Supports, Heel Lifts Water Piks Whirlpools/Whirlpool Equipment Wigs/Toupees