Master List of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items Potentially Subject to Conditions of Payment

CMS has streamlined regulatory requirements to help simplify DMEPOS payment requirements and reduce provider and supplier burden. The Master List serves as a library of Fee-for-Service DMEPOS codes that were flagged as potential vulnerabilities based on the criteria outlined in CMS-1713-F.

As of April 13, 2026, the Master List includes 530 items. View the Master List (PDF).

What Does the Master List Mean for Providers and Suppliers?

Providers and suppliers don’t need to take action unless an item on the Master List also appears on one or both Required Lists:

Required Prior Authorization List (PDF)
As of April 13, 2026, this list includes 74 items.
Required Face-to-Face Encounter and Written Order Prior to Delivery List (PDF)
As of April 13, 2026, this list includes 83 items.

The Required Lists Comparison Chart (PDF) is a side-by-side crosswalk of both Required Lists.

Master List Life Cycle

Step 1. CMS Selects Items for the Master List: Per statute (CMS-1713-F); The item appears to be a source of potential fraud or unnecessary utilization based on an OIG report, GAO report, or CERT Improper Payment Data report (and the item also meets the applicable cost threshold). The item has been subject to aberrant billing patterns. (Aberrant billing is suggested when an item with at least 1,000 claims and $1 million in payments during a recent 12-month period shows an unexpected increase in billed claims without explanatory contributing factors (such as new technology or updated coverage policies.) Step 2: CMS Periodically Selects Items from the Master List to Include on One or Both Required Lists: CMS considers factors such as geographic location, item utilization or cost, system capabilities, emerging trends, vulnerabilities identified in official agency reports, or other analysis. Step 3: CMS Issues a Formal Notice. When items from the Master List are added to one or both Required Lists: CMS will announce the item(s) selected and a formal notice period of at least 60 days will begin. Step 4: Requirements Take Effect: Requirements only take effect when the formal notice period ends. Required Lists are generally updated annually but may also be updated on an ad hoc basis per statute.

HCPCS Code	On Master List?	Prior Authorization Required?	PA Effective Dates	F2F and Written Order Prior to Delivery?	F2F and WOPD Effective Dates
HCPCS Code A4342	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code A4352	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0193	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates P1: 07/22/2019	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0747	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates P1: 08/12/2024	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 08/12/2024
HCPCS Code L2628	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0984	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0986	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0988	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1002	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1003	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1004	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1005	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1006	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1007	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1008	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1010	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1012	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1030	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1035	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1036	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1037	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1050	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1060	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1070	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1083	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1084	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1087	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1088	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1092	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1093	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1100	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1110	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1150	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1160	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1161	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1170	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1171	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1172	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1180	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1190	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1195	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1200	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1221	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1222	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1223	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1224	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1226	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1232	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1233	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1234	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1235	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1236	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1237	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1238	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1240	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1270	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1280	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1295	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1296	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1390	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1391	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1392	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1405	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E1406	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2000	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2100	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2202	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2203	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2204	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2227	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2228	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2310	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2311	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2312	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2321	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2322	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2325	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2327	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2328	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2329	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2330	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2341	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2342	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2343	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2351	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2368	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2370	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2373	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2374	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2375	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2376	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2378	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2402	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2510	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2606	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2613	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2614	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2616	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2620	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2621	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2626	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2627	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2628	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2629	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2630	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E2631	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5590	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5595	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5600	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5610	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5611	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5613	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5614	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5615	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5616	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5617	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5626	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5628	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5638	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5639	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5640	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code K0002	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0004	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0005	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0006	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0007	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0009	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0010	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0011	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0012	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0455	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0606	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0609	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0730	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0738	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0800	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 4/13/2022 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0801	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 4/13/2022 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0802	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 4/13/2022 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0806	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 4/13/2022 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0807	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 4/13/2022 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0808	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 4/13/2022 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0813	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0814	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0815	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0816	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0820	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0821	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0822	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0823	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0824	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0825	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0826	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0827	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0828	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0829	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0835	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0836	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0837	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0838	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0839	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0840	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0841	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0842	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0843	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0848	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0849	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0850	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0851	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/2018 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 04/17/2023
HCPCS Code K0852	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/18 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 4/17/23
HCPCS Code K0853	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/18 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 4/17/23
HCPCS Code K0854	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/18 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 4/17/23
HCPCS Code L1951	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1960	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1970	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L2000	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2005	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L2006	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2010	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code K0855	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates 9/01/18 Nationwide	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 4/17/23
HCPCS Code L2020	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2030	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2034	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2036	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L2037	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2038	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2050	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2060	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2106	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2108	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2114	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2116	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2126	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2128	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2132	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2134	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2136	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2280	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2350	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2510	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2525	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2526	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2570	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2580	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2624	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L2627	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3330	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3671	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3674	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3720	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3730	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3740	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3761	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3763	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3764	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3765	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3766	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3900	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3901	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3904	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3905	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3960	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L3961	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3962	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3967	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3971	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3973	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3975	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3976	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3977	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3978	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L3981	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L4000	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L4010	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L4020	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L4030	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L4130	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L4631	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5000	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5010	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5020	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5050	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5060	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5100	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5105	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5150	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5160	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5200	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5210	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5220	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5230	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5250	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5270	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5280	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5301	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5312	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5321	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5331	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5341	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5400	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5420	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5430	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5460	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5500	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5505	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5510	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5520	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5530	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5535	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5540	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5560	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5570	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5580	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5585	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5642	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5647	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5648	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5649	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5650	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5651	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5653	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5661	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5665	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5671	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5673	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5677	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A4353	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5679	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5681	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A4393	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5682	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5683	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5700	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5701	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5702	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5703	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5704	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5705	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5706	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A4408	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5707	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A4410	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5711	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5716	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5718	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A5056	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code A5057	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5722	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5724	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A5121	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5726	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5728	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A6021	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5780	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5781	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5782	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5785	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5790	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A6203	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L5795	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5810	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5811	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5812	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5814	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5816	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5818	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5822	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5824	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5826	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5828	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5830	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5840	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5845	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5848	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5856	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5857	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5858	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5859	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5920	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5926	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5930	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5940	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5950	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5960	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5961	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5962	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5964	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5966	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5968	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5973	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5976	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5979	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5980	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5981	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5982	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5984	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5986	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5987	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5988	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5990	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5991	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L6026	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L7366	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L7368	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L8035	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code V2531	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A6219	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code A6238	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code A6242	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code A6251	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code A6266	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code A7030	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code A7031	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0170	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0250	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0251	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0255	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0256	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0260	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0261	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0265	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0266	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0277	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates P1: 07/22/2019	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0290	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 08/12/2024
HCPCS Code E0292	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0293	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0294	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0295	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0296	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0856	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code K0857	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code K0858	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code K0859	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code K0860	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code K0861	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code K0862	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code K0863	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code K0864	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0457	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L0635	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0636	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0639	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0648	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0650	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0651	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0830	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1005	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1680	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1681	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1685	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1686	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1690	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1710	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1730	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1755	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code E0297	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0300	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0301	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 08/12/2024
HCPCS Code E0302	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0303	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0304	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 08/12/2024
HCPCS Code E0316	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0371	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates P1: 07/22/2019	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0372	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates P1: 07/22/2019	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0373	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates P1: 07/22/2019	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0424	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0431	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0433	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0434	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0439	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0466	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0462	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0465	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0467	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0470	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0471	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0472	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0482	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0483	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0490	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0500	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0550	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0562	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0575	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0600	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0601	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0617	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0618	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0620	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0630	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0635	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0636	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0639	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0640	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0650	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0651	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0652	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0656	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0657	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0670	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0675	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0677	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0680	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0681	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0693	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0740	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0744	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0745	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0748	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates P1: 08/12/2024	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 08/12/2024
HCPCS Code E0749	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0760	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates P1: 08/12/2024	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates 08/12/2024
HCPCS Code E0764	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0766	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0781	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0782	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0783	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0784	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0785	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0786	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0791	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0912	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0983	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L1832	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1834	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1840	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1843	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1844	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1845	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1846	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1847	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1848	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1851	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1852	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1860	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1906	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1907	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1932	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1940	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1945	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1950	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code A6023	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code E0194	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code K0003	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates N/A	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates N/A
HCPCS Code L0631	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0637	On Master List? Yes	Prior Authorization Required? Yes	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0638	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L0640	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? Yes	F2F and WOPD Effective Dates
HCPCS Code L1700	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L1720	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5643	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5644	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5645	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates
HCPCS Code L5646	On Master List? Yes	Prior Authorization Required? No	PA Effective Dates	F2F and Written Order Prior to Delivery? No	F2F and WOPD Effective Dates

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01/15/2026 12:19 PM

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