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New Updated Version of the DME/OXY Payment & Coverage Guideline Tool

December 2, 2019

Durable Medical Equipment (DME) providers, Oxygen and Respiratory Therapy Equipment (OXY) providers, and Pharmacy providers with a DME and/or OXY specialty are advised that the MassHealth DME and Oxygen Payment and Coverage Guideline Tool was updated on 11/15/19 and posted on the MassHealth website. To confirm that you are using the most recent version of the tool, go to

The requirements and limits have been updated for the following HCPCS codes: K0738, E0431, E0434, E0429, E0439, and E1392.

HCPCS code A4255 has been removed from the tool.

HCPCS code A9900 now requires a prior authorization.

Effective November 15, 2019, when requesting authorization for RE units, providers will be required to add a line item on the prior authorization (PA) request, using procedure code and modifier combination K0739 U5. This code-modifier combination will replace the current manual process of adding the authorized RE unit dollar amount to a primary HCPCS code. Providers should refer to DME Provider Bulletin 23 or Oxygen and Respiratory Provider Bulletin 18 on the 2019 MassHealth Provider Bulletins webpage and the updated version of the interactive MassHealth DME and Oxygen Payment and Coverage Guideline Tool posted on the MassHealth website.

If you have any questions regarding this change, please contact the LTSS Provider Service Center at or call (844) 368-5184.