Nebraska Medicaid Fee Schedule, DME-POS July 1, 2017

Transcription

1 CODE MOD DESCRIPTION Why Auth is Required A4224 SUPPLIES FOR MAINTENANCE OF INSULIN INFUSION CATHETER, PER WEEK No A4225 SUPPLIES FOR EXTERNAL INSULIN INFUSION PUMP, SYRINGE TYPE CARTRIDGE, STERILE, EACH No A4230 INFUSION SET FOR EXTERNAL INSULIN PUMP, NON NEEDLE CANLA TYPE No A4231 INFUSION SET FOR EXTERNAL INSULIN PUMP, NEEDLE TYPE No A4248 CHLORHEXIDINE CONTAINING ANTISEPTIC, 1 ML No A4250 URINE TEST OR REAGENT STRIPS OR TABLETS No A4252 BLOOD KETONE TEST OR REAGENT STRIP, EACH, no A4261 CERVICAL CAP FOR CONTRACEPTIVE USE No A4266 DIAPHRAGM FOR CONTRACEPTIVE USE No A4269 CONTRACEPTIVE SUPPLY, SPERMICIDE (E.G., FOAM, GEL), EACH No A4281 TUBING FOR BREAST PUMP, REPLACEMENT No A4282 ADAPTER FOR BREAST PUMP, REPLACEMENT No A4283 CAP FOR BREAST PUMP BOTTLE, REPLACEMENT No A4284 BREAST SHIELD & SPLASH PROTECTOR FOR USE W/BREAST PUMP, REPLACEMENT No A4285 POLYCARBONATE BOTTLE FOR USE W/BREAST PUMP, REPLACEMENT No A4286 LOCKING RING FOR BREAST PUMP, REPLACEMENT No A4290 SACRAL NERVE STIMULATION TEST LEAD, EACH No A4335 INCONTINENCE SUPPLY, MISCELLANEOUS, no A4337 INCONTINENCE SUPPLY, RECTAL INSERT, ANY TYPE, EACH No A4420 OSTOMY POUCH, CLOSED, FOR USE ON BAIER W/LOCKING FLANGE (2 PIECE), EACH No A4421 OSTOMY SUPPLY, MISCELLANEOUS, no A4435 OSTOMY POUCH, DRAINABLE, HIGH OUTPUT, W/EXTENDED WEAR BAIER (1 PIECE SYSTEM), W/ OR W/O FILTER, EACH No A4458 ENEMA BAG W/TUBING, REUSABLE No A4465 NON-ELASTIC BINDER FOR EXTREMITY No A4466 GARMENT, BELT, SLEEVE OR OTHER COVERING, ELASTIC OR SIMILAR STRETCHABLE MATERIAL, ANY TYPE, EACH No A4467 BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE No A4483 MOISTURE EXCHANGER, DISPOSABLE, FOR USE W/ INVASIVE MECHANICAL VENTILATION No A4553 NON-DISPOSABLE UNDERPADS, ALL SIZES No A4565 SLINGS No A4600 SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE, REPLACEMENT ONLY, EACH No A4601 LITHIUM ION BATTERY FOR NON-PROSTHETIC USE, REPLACEMENT No A4606 RB OXYGEN PROBE FOR USE W/OXIMETER DEVICE, REPLACEMENT No A4613 RB BATTERY CHARGER, REPLACEMENT FOR PATIENT-OWNED VENTILATOR No A TRACHEAL SUCTION CATHETER, ANY TYPE OTHER THAN CLOSED SYSTEM, EACH No A4649 SURGICAL SUPPLIES, MISCELLANEOUS, No A4663 RB BLOOD PRESSURE CUFF ONLY No A AUTOMATIC BLOOD PRESSURE MONITOR - TALKING No A4911 DRAIN BAG/BOTTLE, FOR DIALYSIS, EACH No A4928 SURGICAL MASK, PER 20 No A5057 OSTOMY POUCH, DRAINABLE, W/EXTENDED WEAR BAIER ATTACHED, W/BUILT- IN CONVEXITY, W/FILTER, (1 PIECE), EACH No A5508 DELUXE FEATURE OF OFF-THE-SHELF DEPTH-INLAY OR CUSTOM-MOLDED SHOE, PER SHOE No A5510 DIRECT FORMED, COMPRESSION MOLDED TO PATIENT'S FOOT W/O EXTERNAL HEAT SOURCE, MULTIPLE DENSITY INSERT(S) PREFABRICATED No A6025 GEL SHEET FOR DERMAL OR EPIDERMAL APPLICATION, (E.G., SILICONE, HYDROGEL, OTHER), EACH No A6198 ALGINATE OR OTHER FIBER GELLING DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., No EACH DRESSING A6205 COMPOSITE DRESSING, STERILE, PAD SIZE MORE THAN 48 SQ. IN., W/ANY SIZE ADHESIVE BORDER, EACH DRESSING No A6206 CONTACT LAYER, STERILE, 16 SQ. IN. OR LESS, EACH DRESSING No A6208 CONTACT LAYER, STERILE, MORE THAN 48 SQ. IN., EACH DRESSING No A6213 FOAM DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., W/ ANY SIZE ADHESIVE BORDER, EACH No A6215 FOAM DRESSING, WOUND FILLER, STERILE, PER GRAM No A6218 GAUZE, NON-IMPREGNATED, NON-STERILE, MORE THAN 48 SQ IN, W/O ADHESIVE BORDER, EACH DRESSING No A6221 GAUZE, NON-IMPREGNATED, STERILE, PAD SIZE MORE THAN 48 SQ. IN., W/ ANY SIZE ADHESIVE BORDER, EACH DRESSING No A6228 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE 16 SQ. IN. OR LESS, W/O ADHESIVE BORDER, EACH DRESSING No A6230 GAUZE, IMPREGNATED, WATER OR NORMAL SALINE, STERILE, PAD SIZE MORE THAN 48 SQ. IN., W/O ADHESIVE BORDER, EACH DRESSING No A6239 HYDROCOLLOID DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ.IN., W/ANY SIZE ADHESIVE BORDER, EACH DRESSING No A6256 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, PAD SIZE MORE THAN 48 SQ. IN., W/ANY SIZE ADHESIVE BORDER, EACH DRESSING No A6261 WOUND FILLER, GEL/PASTE, STERILE, PER FLUID OUNCE, NOT OTHERWISE SPECIFIED No A6262 WOUND FILLER, DRY FORM, STERILE, PER GRAM, NOT OTHERWISE SPECIFIED No A6404 GUAZE, NON-IMPREGNATED, STERILE, MORE THAN 48 SQ. IN., W/O ADHESIVE BORDER, EACH DRESSING No A6413 ADHESIVE BANDAGE, FIRST-AID TYPE, ANY SIZE, EACH No WellCare 2018 NE8PROGDE13753E_0000 Page 1 of 36

2 A6450 LIGHT COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO FIVE IN., PER YARD No A6451 MODERATE COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE OF 1.25 TO 1.34 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN No A6501 COMPRESSION BURN GARMENT, BODYSUIT (HEAD TO FOOT), CUSTOM FABRICATED No A6502 COMPRESSION BURN GARMENT, CHIN STRAP, CUSTOM FABRICATED No A6503 COMPRESSION BURN GARMENT, FACIAL HOOD, CUSTOM FABRICATED No A6504 COMPRESSION BURN GARMENT, GLOVE TO WRIST, CUSTOM FABRICATED No A6505 COMPRESSION BURN GARMENT, GLOVE TO ELBOW, CUSTOM FABRICATED No A6506 COMPRESSION BURN GARMENT, GLOVE TO AXILLA, CUSTOM FABRICATED No A6507 COMPRESSION BURN GARMENT, FOOT TO KNEE LENGTH, CUSTOM FABRICATED No A6508 COMPRESSION BURN GARMENT, FOOT TO THIGH LENGTH, CUSTOM FABRICATED No A6509 COMPRESSION BURN GARMENT, UPPER TRUNK TO WAIST INCLUDING ARM OPENINGS (VEST), CUSTOM FABRICATED No A6510 COMPRESSION BURN GARMENT, TRUNK, INCLUDING ARMS DOWN TO LEG OPENINGS (LEOTARD), CUSTOM FABRICATED No A6511 COMPRESSION BURN GARMENT, LOWER TRUNK INCLUDING LEG OPENINGS (PANTY), CUSTOM FABRICATED No A6512 COMPRESSION BURN GARMENT, NOT OTHERWISE CLASSIFIED No A6513 COMPRESSION BURN MASK, FACE AND/OR NECK, PLASTIC OR EQUAL, CUSTOM FABRICATED No A6540 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, MMHG, EACH No A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, MM HG, EACH No A6549 GRADIENT COMPRESSION STOCKING/SLEEVE, NOT OTHERWISE SPECIFIED No A7011 COUGATED TUBING, NON-DISPOSABLE, USED W/ LARGE VOLUME NEBULIZER, 10 FT No A7020 INTERFACE FOR COUGH STIMULATING DEVICE, INCLUDES ALL COMPONENTS No A7028 ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH No A7029 NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR No A7047 ORAL INTERFACE USED WITH RESPIRATORY SUCTION PUMP, EACH No A7523 TRACHEOSTOMY SHOWER PROTECTOR, EACH No A8003 HELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES No A9285 INVERSION/EVERSION COECTION DEVICE No A9286 HYGIENIC ITEM OR DEVICE, DISPOSABLE OR NON-DISPOSABLE, ANY TYPE, EACH No A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE No A9999 MISCELLANEOUS DME SUPPLY OR ACCESSORY, NOT OTHERWISE SPECIFIED No B4088 GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE, ANY MATERIAL, ANY TYPE, EACH No B4157 ENTERAL FORMULA, TRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE No OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES B4157 BO ENTERAL FORMULA, TRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE No OF METABOLISM. 100 CAL = 1 UNIT B4162 ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS No B4162 BO ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE OF METABOLISM. 100 CALORIES = 1 UNIT No B5200 PARENTERAL TRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS, VITAMINS, INCLUDING PREP.; PREMIX No B9000 ENTERAL TRITION INFUSION PUMP - WITHOUT ALARM No B9000 LL ENTERAL TRITION INFUSION PUMP - WITHOUT ALARM No B9000 MS ENTERAL TRITION INFUSION PUMP-WITHOUT ALARM. MAINTENANCE AND SERVICING FEE FOR REASONABLE NECESSARY PARTS & LABOR No B9000 ENTERAL TRITION PUMP WITHOUT ALARM No B9000 ENTERAL TRITION INFUSION PUMP-WITHOUT ALARM No B9002 LL ENTERAL TRITION INFUSION PUMP No B9002 ENTERAL TRITION INFUSION PUMP-WITH ALARM B9002 RB ENTERAL TRITION INFUSION PUMP-WITH ALARM, CLIENT-OWNED, REPAIR B9998 NOC FOR ENTERAL SUPPLIES. No E CRUTCHES, UNDERARM, BARIATRIC (CLIENT'S WEIGHT OVER 250 POUNDS),OTHER THAN WOOD, ADJUSTABLE OR FIXED, PAIR No E0118 CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACH No E0118 CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACH No E0118 CRUTCH SUBSTITUTE, LOWER LEG PLATFORM, WITH OR WITHOUT WHEELS, EACH No E WALKER, RIGID (PICKUP) ADJ OR FIXED HEIGHT, no E0135 LL WALKER, FOLDING (PICKUP) ADJ OR FIXED HEIGHT No E0143 LL WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED HEIGHT No E0170 COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM, ELECTRIC, ANY TYPE E0172 SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE No E0172 SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE No E0172 SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE No E0190 POSITIONING CUSHION/PILLOW/WEDGE, ANY SHAPE OR SIZE, INCLUDES ALL COMPONENTS AND ACCES. No E0190 POSITIONING CUSHION/PILLOW/WEDGE, ANY SHAPE OR SIZE, INCLUDES ALL COMPONENTS AND ACCES. No E0190 POSITIONING CUSHION/PILLOW/WEDGE, ANY SHAPE OR SIZE, INCLUDES ALL COMPONENTS AND ACCES. No E0193 POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY) E0194 AIR FLUIDIZED BED E0221 INFRARED HEATING PAD SYSTEM E0236 RB PUMP FOR WATER CIRCULATING PAD No E0240 BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE No E0240 BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE No E0240 BATH/SHOWER CHAIR, WITH OR WITHOUT WHEELS, ANY SIZE No E TUB STOOL OR BENCH., no WellCare 2018 NE8PROGDE13753E_0000 Page 2 of 36

3 E0247 TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING No E0247 TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING No E0247 TRANSFER BENCH FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING No E0248 TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING No E0248 TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING No E0248 TRANSFER BENCH, HEAVY DUTY, FOR TUB OR TOILET WITH OR WITHOUT COMMODE OPENING No E0250 HOSPITAL BED, FIXED HEIGHT, WITH ANY TYPE SIDE RAILS, WITH MATTRESS E0255 HOSPITAL BED, VARIABLE HGT HI-LO, WITH ANY TYPE SIDE RAILS, WITH MATTRESS E0256 HOSPITAL BED, VARIABLE HGT HI-LO, WITH ANY TYPE SIDE RAILS W/O MATTRESS E0260 LL HOSPITAL BED, SEMI-ELEC (HEAD & FT ADJ) WITH ANY TYPE SIDE RAILS W/ MATTRESS No E0260 HOSPITAL BED, SEMI-ELEC (HEAD & FT ADJ) WITH ANY TYPE SIDE RAILS W/ MATTRESS E0260 UE HOSPITAL BED, SEMI-ELEC (HEAD & FT ADJ) WITH ANY TYPE SIDE RAILS W/ MATTRESS E0261 HOSPITAL BED, SEMI-ELEC (HEAD & FT ADJ) WITH ANY TYPE SIDE RAILS W/O MATTRESS E0265 HOSPITAL BED, ELECTRIC (HEAD, FT & HGT ADJ) W/ ANY TYPE SIDE RAILS W/ MATTRESS E0265 UE HOSPITAL BED, ELECTRIC (HEAD, FT & HGT ADJ) WITH ANY TYPE SIDE RAILS W/ MATTRESS E0266 HOSPITAL BED, ELECTRIC (HEAD, FT & HGT ADJ) WITH ANY TYPE RAILS W/O MATTRESS E0271 LL MATTRESS, INNERSPRING No E0292 HOSP BED, VARIABLE HEIGHT, HI-LO, WITHOUT SIDE RAILS, WITH MATTRESS E0294 HOSP BED, SEMI ELEC, WITHOUT SIDE RAILS, WITH MATTRESS E0295 HOSP BED, SEMI ELEC, WITHOUT SIDE RAILS, WITHOUT MATTRESS E0296 HOSP BED, TOTAL ELEC, WITHOUT SIDE RAILS, WITH MATTRESS E0297 HOSP BED, TOTAL ELEC, WITHOUT SIDE RAILS, WITHOUT MATTRESS E0300 PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED E0300 PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED E0300 PEDIATRIC CRIB, HOSPITAL GRADE, FULLY ENCLOSED E0301 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE E0301 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE E0301 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE E0302 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS E0302 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS E0302 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS E0303 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE E0303 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE E0303 HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE E HOSPITAL BED, HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 350 POUNDS, BUT LESS, no THAN OR EQUAL TO 600 POUNDS, WITH ANY TYPE SIDE E0304 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS E0304 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS E0304 HOSPITAL BED, EXTRA HEAVY DUTY, EXTRA WIDE, WITH WEIGHT CAPACITY GREATER THAN 600 POUNDS, WITH ANY TYPE SIDE RAILS, WITH MATTRESS E0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE E0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE E0316 SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE E SAFETY ENCLOSURE FRAME/CANOPY FOR USE WITH HOSPITAL BED, ANY TYPE, no E0328 HOSPITAL BED, PEDIATRIC, MAAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLU No E0328 HOSPITAL BED, PEDIATRIC, MAAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLU No E0328 HOSPITAL BED, PEDIATRIC, MAAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLU No E0329 HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE No E0329 HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE No E0329 HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE No E0370 AIR PRESSURE ELEVATOR FOR HEEL No E0371 NONPOWERED ADVANCED PRESSURE REDUCING OVERLAY FOR MATTRESS, STD LGTH/WID E0373 NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS E0450 VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL No MODE, USED WITH INVASIVE INTERFACE (E.G., TRACHEOSTOMY T E0450 MS VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL No MODE, USED WITH INVASIVE INTERFACE (E.G., TRACHEOSTOMY T E0450 VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL No MODE, USED WITH INVASIVE INTERFACE (E.G., TRACHEOSTOMY T E0453 THERAPEUTIC VENTILATOR; SUITABLE FOR 12 HRS OR LESS PER DAY E0455 RA OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS No E0455 RB OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS No WellCare 2018 NE8PROGDE13753E_0000 Page 3 of 36

4 E0460 NEGATIVE PRESSURE VENTILATOR,PORTABLE OR STATIONARY No E0460 NEGATIVE PRESSURE VENTILATOR,PORTABLE OR STATIONARY No E0461 VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL No MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK) E0461 VOLUME CONTROL VENTILATOR, WITHOUT PRESSURE SUPPORT MODE, MAY INCLUDE PRESSURE CONTROL No MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK) E0463 PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH INVASIVE INTERFACE (E.G. TRACHEOSTOMY TU No E0463 PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH INVASIVE INTERFACE (E.G. TRACHEOSTOMY TU No E0464 PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK) No E0464 PRESSURE SUPPORT VENTILATOR WITH VOLUME CONTROL MODE, MAY INCLUDE PRESSURE CONTROL MODE, USED WITH NON-INVASIVE INTERFACE (E.G. MASK) No E0465 HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE INTERFACE, (E.G., TRACHEOSTOMY TUBE) No E0465 HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE INTERFACE, (E.G., TRACHEOSTOMY TUBE) E0465 HOME VENTILATOR, ANY TYPE, USED WITH INVASIVE INTERFACE, (E.G., TRACHEOSTOMY TUBE) E0466 HOME VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL) No E0466 HOME VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL) E0466 HOME VENTILATOR, ANY TYPE, USED WITH NON-INVASIVE INTERFACE, (E.G., MASK, CHEST SHELL) E0470 LL RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL No E0470 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL E0480 LL PERCUSSOR, ELECTRIC OR PNEUMATIC, HOME MODEL No E0482 COUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESSURE E0483 LL HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM, (INCLUDES HOSES & VEST), EACH E0483 HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM, (INCLUDES HOSES & VEST), EACH E0485 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT No E0485 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT No E0485 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON ADJUSTABLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT No E0486 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT No E0486 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT No E0486 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT No E0487 SPIROMETER, ELECTRONIC, INCLUDES ALL ACCESSORIES No E0487 SPIROMETER, ELECTRONIC, INCLUDES ALL ACCESSORIES No E0487 SPIROMETER, ELECTRONIC, INCLUDES ALL ACCESSORIES No E0500 LL IPPB MACHINE, ALL TYPES, WITH BUILT-IN NEBULIZATION; MAAL OR AUTO VALVE No E0500 IPPB MACHINE E0550 RA HUMIDIFIER, DURABLE FOR EXT SUPP HUMID IPPB TREATMENTS OR OXY DELIVERY E0550 RB HUMIDIFIER, DURABLE FOR EXT SUPP HUMID IPPB TREATMENTS OR OXY DELIVERY E0570 LL NEBULIZER WITH COMPRESSOR. No E0575 NEBULIZER, ULTRASONIC, LARGE VOLUME E0600 LL RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC No E0601 LL CONTIOUS AIRWAY PRESSURE CPAP DEVICE No E0601 CONTIOUS AIRWAY PRESSURE CPAP DEVICE E0617 EXTERNAL DEFIBRILLATOR WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS E0625 PATIENT LIFT, BATHROOM OR TOILET, NOT OTHERWISE CLASSIFIED E0625 PATIENT LIFT, BATHROOM OR TOILET, NOT OTHERWISE CLASSIFIED, no E0625 PATIENT LIFT, BATHROOM OR TOILET, NOT OTHERWISE CLASSIFIED E0627 SEAT LIFT MECHANISM INCORP COMBINATION LIFT CHAIR MECHANISM E0627 SEAT LIFT MECHANISM INCORP COMBINATION LIFT CHAIR MECHANISM WellCare 2018 NE8PROGDE13753E_0000 Page 4 of 36

5 E0627 SEAT LIFT MECHANISM INCORP COMBINATION LIFT CHAIR MECHANISM E0627 UE SEAT LIFT MECHANISM INCORP COMBINATION LIFT CHAIR MECHANISM E SEAT LIFT MECHANISM INCORP COMBINATION LIFT CHAIR MECHANISM No E0628 SEPARATE SEAT LIFT MECHANISM W/ PATIENT OWNED FURNITURE-ELEC No E0628 SEPARATE SEAT LIFT MECHANISM W/ PATIENT OWNED FURNITURE-ELEC No E0628 SEPARATE SEAT LIFT MECHANISM W/ PATIENT OWNED FURNITURE-ELEC No E0629 SEPARATE SEAT LIFT MECHANISM W/ PATIENT OWNED FURNITURE-NON ELEC E0629 SEPARATE SEAT LIFT MECHANISM W/ PATIENT OWNED FURNITURE-NON ELEC E0629 SEPARATE SEAT LIFT MECHANISM W/ PATIENT OWNED FURNITURE-NON ELEC E0630 PATIENT LIFT, HYDRAULIC OR MECHANICAL, INCLUDES ANY SEAT, SLING, STRAP(S) OR PAD(S) E0635 PATIENT LIFT,ELEC,W/ SEAT OR SLING E0636 MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENT ACCESSIBLE CONTROLS E0636 MULTIPOSITIONAL PATIENT SUPPORT SYSTEM, WITH INTEGRATED LIFT, PATIENT ACCESSIBLE CONTROLS E0637 COMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFT FEATURE, WITH OR WITHOUT WHEELS No E0637 COMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFT FEATURE, WITH OR WITHOUT WHEELS No E0637 COMBINATION SIT TO STAND SYSTEM, ANY SIZE INCLUDING PEDIATRIC, WITH SEATLIFT FEATURE, WITH OR WITHOUT WHEELS No E0638 STANDING FRAME SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS No E0638 STANDING FRAME SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS No E0638 STANDING FRAME SYSTEM, ONE POSITION (E.G. UPRIGHT, SUPINE OR PRONE STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS No E0639 PATIENT LIFT, MOVEABLE FROM ROOM TO ROOM WITH DISASSEMBLY AND REASSEMBLY, INCLUDES ALL COMPONENTS/ACCESSORIES No E0639 PATIENT LIFT, MOVEABLE FROM ROOM TO ROOM WITH DISASSEMBLY AND REASSEMBLY, INCLUDES ALL COMPONENTS/ACCESSORIES No E0639 PATIENT LIFT, MOVEABLE FROM ROOM TO ROOM WITH DISASSEMBLY AND REASSEMBLY, INCLUDES ALL COMPONENTS/ACCESSORIES No E PATIENT LIFT, FIXED SYSTEM, INCLUDES ALL COMPONENTS/ACCESSORIES (ACCOMPANYING BRACKETS, SWITCH, ACCESSORIES, AND TWO SLINGS/BODY SUPPORTS) No E0641 STANDING FRAME SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS No WellCare 2018 NE8PROGDE13753E_0000 Page 5 of 36

6 E0641 STANDING FRAME SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS No E0641 STANDING FRAME SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS No E0642 STANDING FRAME SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC No E0642 STANDING FRAME SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC No E0642 STANDING FRAME SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC No E0650 PNEUMATIC COMPRESSOR, NON SEGMENTAL HOME MODEL E PNEUMATIC COMPRESSOR, NON SEGMENTAL HOME MODEL No E0651 PNEUMATIC COMP, SEGMENTAL HOME MODEL WITHOUT CAL GRADIENT PRESSURE E0652 PNEUMATIC COMP, SEGMENTAL HOME MODEL W/ CALIBRATED GRADIENT PRESSURE E0657 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, CHEST No E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK No E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK No E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK No E0675 PNEUMATIC COMPRESSION DEVICE, HIGH PRESSURE, RAPID INFLATION/DEFLATION CYCLE, FOR ARTERIAL INSUFFICIENCY (UNILATERAL OR BILATERAL SYSTEM) E0691 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS E0691 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS E0691 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION; TREATMENT AREA 2 SQUARE FEET OR LESS E0692 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 4 FOOT PANEL E0692 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 4 FOOT PANEL E0692 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 4 FOOT PANEL E0693 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 6 FOOT PANEL E0693 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 6 FOOT PANEL E0693 ULTRAVIOLET LIGHT THERAPY SYSTEM PANEL, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION, 6 FOOT PANEL E0694 ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION WellCare 2018 NE8PROGDE13753E_0000 Page 6 of 36

7 E0694 E0694 Nebraska Medicaid Fee Schedule, DME-POS July 1, 2017 ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION ULTRAVIOLET MULTIDIRECTIONAL LIGHT THERAPY SYSTEM IN 6 FOOT CABINET, INCLUDES BULBS/LAMPS, TIMER AND EYE PROTECTION E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED E0720 LL TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED, no E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED E0720 UE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION E0730 LL TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR, no MULTIPLE NERVE STIMULATION E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION E0730 UE TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION E0745 LL NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT - CONVERT TO PURCHASE No E0745 NEUROMUSCULAR STIMULATOR, ELECTRIC SHOCK UNIT E0745 UE NEUROMUSCULAR STIMULATOR, ELECTRIC SHOCK UNIT E0746 ELECTROMYOGRAPHY (EMG),BIOFEEDBACK DEVICE No E0746 ELECTROMYOGRAPHY (EMG),BIOFEEDBACK DEVICE No E0746 ELECTROMYOGRAPHY (EMG),BIOFEEDBACK DEVICE No E0747 OSTEOGENESIS STIM, ELEC,NON-INVASIVE,OTHER THAN SPINAL APPL E0748 OSTEOGENIC STIMULATOR, SPINAL APPLICATIONS E0748 RA OSTEOGENIC STIMULATOR, SPINAL APPLICATIONS No E0748 RB OSTEOGENIC STIMULATOR, SPINAL APPLICATIONS No E0755 ELECTRONIC SALIVARY REFLEX. No E0766 ELECTRICAL STIMULATION DEVICE USED FOR CANCER TREATMENT, INCL ALL ACCESSORIES, ANY TYPE No E0766 ELECTRICAL STIMULATION DEVICE USED FOR CANCER TREATMENT, INCL ALL ACCESSORIES, ANY TYPE No E0766 ELECTRICAL STIMULATION DEVICE USED FOR CANCER TREATMENT, INCLALL ACCESSORIES, ANY TYPE No E0770 FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOT OTHERWISE SPECIFIED No E0781 AMBULATORY INFUSION PUMP, SINGLE OR MULTIPLE CHANNELS, ELECTRIC OR BATTERY OPERATED, WITH ADMINISTRATIVE EQUIPMENT WORN BY PATIENT. E0784 EXTERNAL AMBULATORY INFUSION PUMP, INSULIN E0791 PARENTERAL INFUSION PUMP,STATIONARY,SGL OR MULTI CHANNEL E0830 AMBULATORY TRACTION DEVICE, ALL TYPES, EACH No E0830 AMBULATORY TRACTION DEVICE, ALL TYPES, EACH No E0830 AMBULATORY TRACTION DEVICE, ALL TYPES, EACH No E0856 CERVICAL TRACTION DEVICE, W/ INFLATABLE AIR BLADDERS(S) No E0856 CERVICAL TRACTION DEVICE, W/ INFLATABLE AIR BLADDER(S) No E0856 CERVICAL TRACTION DEVICE, W/ INFLATABLE AIR BLADDER(S) No E0912 TRAPEZE BAR, HEAVY DUTY, FOR PATIENT WEIGHT CAPACITY GREATER THAN 250 POUNDS, FREE STANDING, COMPLETE WITH GRAB BAR E0950 KA WHEELCHAIR ACCESSORY, TRAY, EACH E0950 WHEELCHAIR ACCESSORY, TRAY, EACH E0950 MS WHEELCHAIR ACCESSORY, TRAY, EACH E0950 WHEELCHAIR ACCESSORY, TRAY, EACH E0950 WHEELCHAIR ACCESSORY, TRAY, EACH E0951 KA HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH E0951 MS HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH E0952 KA TOE LOOP/HOLDER, ANY TYPE, EACH E0952 TOE LOOP/HOLDER, ANY TYPE, EACH E0952 MS TOE LOOP/HOLDER, ANY TYPE, EACH E0952 TOE LOOP/HOLDER, ANY TYPE, EACH E0952 TOE LOOP/HOLDER, ANY TYPE, EACH WellCare 2018 NE8PROGDE13753E_0000 Page 7 of 36

8 E0955 KA WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCL FIXED MOUNTING HARDWARE, EA E0955 WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCL FIXED MOUNTING HARDWARE, EA E0955 MS WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCL FIXED MOUNTING HARDWARE, EA E0955 WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCL FIXED MOUNTING HARDWARE, EA E0955 WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCL FIXED MOUNTING HARDWARE, EA E0956 E0956 E0956 E0956 E0956 E0957 KA WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH MS WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH WHEELCHAIR ACCESSORY, LATERAL TRUNK OR HIP SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH E0957 MS WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCL FIXED MOUNTING HARDWARE, EA E0957 WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCL FIXED MOUNTING HARDWARE, EA E0957 WHEELCHAIR ACCESSORY, MEDIAL THIGH SUPPORT, ANY TYPE, INCL FIXED MOUNTING HARDWARE, EA E0958 KA MAAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH E0958 MAAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH E0958 MS MAAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH ACCESSORY, ONE-ARM DRIVE ATTACHMENT, E0958 MAAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH E0958 MAAL WHEELCHAIR ACCESSORY, ONE-ARM DRIVE ATTACHMENT, EACH E0959 KA MAAL WHEELCHAIR ACCESSORY, ADAPTOR FOR AMPUTEE, EACH E0959 MAAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH E0959 MS MAAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH E0959 MAAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH E0959 MAAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH E0960 E0960 E0960 E0960 E0960 KA WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE MS WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE WHEELCHAIR ACCESSORY, SHOULDER HARNESS/STRAPS OR CHEST STRAP, INCLUDING ANY TYPE MOUNTING HARDWARE E0961 KA MAAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH E0961 MAAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH E0961 MS MAAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH E0961 MAAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH E0961 MAAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH E0966 KA MAAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH E0966 MAAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH E0966 MS MAAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH E0966 MAAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH E0966 MAAL WHEELCHAIR ACCESSORY, HEADREST EXTENSION, EACH E0967 KA MAAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACH E0967 MAAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACH E0967 MS MAAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACH E0967 MAAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACH E0967 MAAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE, EACH E0968 KA COMMODE SEAT, WHEELCHAIR WellCare 2018 NE8PROGDE13753E_0000 Page 8 of 36

9 E0968 COMMODE SEAT, WHEELCHAIR E0968 COMMODE SEAT, WHEELCHAIR E0968 COMMODE SEAT, WHEELCHAIR E0969 NAOWING DEVICE, WHEELCHAIR E0969 NAOWING DEVICE, WHEELCHAIR E0969 NAOWING DEVICE, WHEELCHAIR E0971 KA MAAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH E0971 MAAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH E0971 MS MAAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH E0971 MAAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH E0971 MAAL WHEELCHAIR ACCESSORY, ANTI-TIPPING DEVICE, EACH E0973 KA WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH E0973 MS WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE ASSEMBLY, EACH E0974 KA MAAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH E0974 MAAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH E0974 MS MAAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH E0974 MAAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH E0974 MAAL WHEELCHAIR ACCESSORY, ANTI-ROLLBACK DEVICE, EACH E0978 KA WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH E0978 MS WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH E0978 RB WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH E0983 KA MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL E0983 MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL E0983 MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL E0983 MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL E0984 KA MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL E0984 MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL E0984 MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL E0984 RB MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL E0984 MAAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MAAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL E0985 KA WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM E0986 KA MAAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACH E0986 MAAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACH E0986 MAAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACH E0986 RA MAAL WHEELCHAIR ACCESSORY, PUSH-RIM ACTIVATED POWER ASSIST SYSTEM E0986 RB MAAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACH E0986 MAAL WHEELCHAIR ACCESSORY, PUSH ACTIVATED POWER ASSIST, EACH E0990 KA WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH WellCare 2018 NE8PROGDE13753E_0000 Page 9 of 36

10 E0990 MS WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH E0992 KA MAAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT E0992 MAAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT E0992 MS MAAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT E0992 MAAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT E0992 MAAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT E0994 KA ARMREST, EACH E0994 ARMREST, EACH E0994 ARMREST, EACH E0994 ARMREST, EACH E0995 KA WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH E0995 MS WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, EACH E1002 KA WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY E1002 RB WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY E1003 KA WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION E1003 RB WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION E1004 KA WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION E1004 RB WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION E1005 KA WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION E1005 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION E1005 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION E1005 RB WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION E1005 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION E1006 KA WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION E1006 RB WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION E1007 KA WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE WITH MECHANICAL SHEAR REDUCTION E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION E1007 RB WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION E1008 KA WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION WellCare 2018 NE8PROGDE13753E_0000 Page 10 of 36

11 E1008 E1008 E1008 E1008 E1009 E1009 E1009 E1009 E1009 0E1010 E1010 E1010 E1010 E1010 E1011 E1011 E1011 E1011 E1012 Nebraska Medicaid Fee Schedule, DME-POS July 1, 2017 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION RB WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION KA WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION, no SYSTEM, INCLUDING PUSH ROD AND LEG REST, EACH WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION, no SYSTEM, INCLUDING PUSH ROD AND LEG REST, EACH WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION, no SYSTEM, INCLUDING PUSH ROD AND LEG REST, EACH RB WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION, no SYSTEM, INCLUDING PUSH ROD AND LEG REST, EACH WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION, no SYSTEM, INCLUDING PUSH ROD AND LEG REST, EACH KA WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR RB WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR KA MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED, no WITH INITIAL CHAIR) MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR) No MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR) No MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO BE DISPENSED WITH INITIAL CHAIR) No WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH E1014 KA RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR E1014 RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR E1014 RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR E1014 RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR E1015 KA SHOCK ABSORBER FOR MAAL WHEELCHAIR, EACH E1015 SHOCK ABSORBER FOR MAAL WHEELCHAIR, EACH E1015 SHOCK ABSORBER FOR MAAL WHEELCHAIR, EACH E1015 RB SHOCK ABSORBER FOR MAAL WHEELCHAIR, EACH E1015 SHOCK ABSORBER FOR MAAL WHEELCHAIR, EACH E1016 KA SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MAAL WHEELCHAIR, EACH E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MAAL WHEELCHAIR, EACH E1017 RB HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MAAL WHEELCHAIR, EACH E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MAAL WHEELCHAIR, EACH E1018 KA HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH E1018 RB HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER WHEELCHAIR, EACH, no, no, no, no, no, no, no, no E1020 KA RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR WHEELCHAIR ACCESSORY, MAAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE E1028 KA FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSOR WellCare 2018 NE8PROGDE13753E_0000 Page 11 of 36

12 E1028 E1028 E1028 Nebraska Medicaid Fee Schedule, DME-POS July 1, 2017 WHEELCHAIR ACCESSORY, MAAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING AC WHEELCHAIR ACCESSORY, MAAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING AC WHEELCHAIR ACCESSORY, MAAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING AC E1029 KA WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED E1030 KA WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED E1030 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED E1030 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED E1030 RB WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED E1030 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED E1035 E1035 E1035 MULTI-POSITIONAL PATIENT TRANSFER SYSTEM, WITH INTEGRATED SEAT, OPERATED BY CARE GIVER, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 LBS MULTI-POSITIONAL PATIENT TRANSFER SYSTEM, WITH INTEGRATED SEAT, OPERATED BY CARE GIVER, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 LBS MULTI-POSITIONAL PATIENT TRANSFER SYSTEM, WITH INTEGRATED SEAT, OPERATED BY CARE GIVER, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 LBS E1037 TRANSPORT CHAIR, PEDIATRIC SIZE E1037 TRANSPORT CHAIR, PEDIATRIC SIZE E1037 TRANSPORT CHAIR, PEDIATRIC SIZE E1038 TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT E1038 TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT E1038 TRANSPORT CHAIR, ADULT SIZE, PATIENT WEIGHT E1039 TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS E1039 TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS E1039 TRANSPORT CHAIR, ADULT SIZE, HEAVY DUTY, PATIENT WEIGHT CAPACITY GREATER THAN 300 POUNDS E1050 E1050 E1050 E1060 E1060 E1060 E1070 E1070 E1070 E1070 FULLY RECLINING WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG FULLY RECLINING WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG FULLY RECLINING WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG FULLY RECLINING WHEELCHAIR;DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG RB FULLY RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG FULLY RECLINING WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG FULLY RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE FOOT FULLY RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE FOOT RB FULLY RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE FOOT FULLY RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE FOOT E1083 HEMI-WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1083 HEMI-WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1083 HEMI-WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1084 HEMI-WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG E1084 HEMI-WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG E1084 HEMI-WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG E1087 HIGH-STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1087 HIGH-STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1087 RB HIGH-STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1087 HIGH-STRENGTH LIGHTWEIGHT WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1088 HIGH-STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG E1088 HIGH-STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG E1088 RB HIGH-STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG WellCare 2018 NE8PROGDE13753E_0000 Page 12 of 36

13 E1088 E1092 E1092 E1092 E1092 E1093 E1093 E1093 E1093 E1100 E1100 E1100 E1100 Nebraska Medicaid Fee Schedule, DME-POS July 1, 2017 HIGH-STRENGTH LIGHTWEIGHT WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE ELEVATING LEG WIDE, HEAVY-DUTY WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG WIDE, HEAVY-DUTY WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG RB WIDE, HEAVY-DUTY WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG WIDE, HEAVY-DUTY WHEELCHAIR;DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG WIDE, HEAVY-DUTY WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE FOOT WIDE, HEAVY-DUTY WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE FOOT RB WIDE, HEAVY-DUTY WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE FOOT WIDE, HEAVY-DUTY WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE FOOT SEMI-RECLINING WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG SEMI-RECLINING WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG RB SEMI-RECLINING WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG SEMI-RECLINING WHEELCHAIR; FIXED FULL-LENGTH ARMS,SWING-AWAY, DETACHABLE, ELEVATING LEG E1110 SEMI-RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, ELEVATING LEG REST E1110 SEMI-RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, ELEVATING LEG REST E1110 RB SEMI-RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, ELEVATING LEG REST E1110 SEMI-RECLINING WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, ELEVATING LEG REST E1150 E1150 E1150 E1150 WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG WHEELCHAIR;DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG RB WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE ELEVATING LEG E1160 WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1160 WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1160 WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1161 MAAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE E1161 RB MAAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE E1161 MAAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE E1161 UE MAAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE E1170 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1170 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1170 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1171 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, WITHOUT FOOT OR LEG E1171 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, WITHOUT FOOT OR LEG E1171 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, WITHOUT FOOT OR LEG E1172 AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, WITHOUT FOOT OR LEG E1172 AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH WITHOUT FOOT OR LEG E1172 E1180 E1180 E1180 E1190 E1190 E1190 AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, WITHOUT FOOT OR LEG AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE FOOT AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE FOOT AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE FOOT AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG AMPUTEE WHEELCHAIR; DETACHABLE ARMS, DESK OR FULL-LENGTH, SWING-AWAY, DETACHABLE, ELEVATING LEG E1195 HEAVY DUTY WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1195 HEAVY DUTY WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1195 HEAVY DUTY WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE, ELEVATING LEG E1200 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE FOOT E1200 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE FOOT E1200 AMPUTEE WHEELCHAIR; FIXED FULL-LENGTH ARMS, SWING-AWAY, DETACHABLE FOOT WellCare 2018 NE8PROGDE13753E_0000 Page 13 of 36