July 15, 2004
Mitchell Yaffy
SOS Rehabilitation
St. Laurent, Quebec
H4T-1N3

E-Z Back System & Laterals (Models EZL2001, EZL.2002, EZL2003)
Dear Mr. Yaffy:

The SADMERC and the four Durable Medical Equipment Regional Carriers (DMERCs) have completed the HCPCS Coding Verification Review on January 14,2004 for the above listed product(s) manufactured by SOS Rehabilitation Products, Inc. This review resulted in a consensus coding decision.

It is our detennination that the E-Z Back System & Laterals (Models EZL2001 , EZL2002, EZL2003 meets the description for a wheelchair accessory as defined in the DMERC Medical Policy for Wheelchair Options/Accessories Medical Policy Therefore, the correct Medicare billing code(s) for the product(s) is/are

K0108 Other accessories
This HCPCS coding decision applies to the submitted product(s) as presented to and reviewed by the SADMERC and four DMERCs. Any modifications to this product could change the HCPCS code and would need to be reviewed for coding verification. The assignment of a HCPCS code to this product should in no way be construed as an approval or endorsement of this product by SADMERC or Medicare, nor does it imply or guarantee claim reimbursement or coverage. For questions regarding claim coverage or reimbursement please contact your regional DMERC.

Should you disagree with this coding decision, a re-review of the product(s) can be initiated. The SADMERC will provide a re-review if the request in made within 45 days of the date of this letter and additional documentation is provided supporting the request. If a request for a re- review is made after 45 days, the request is treated as a new Coding Verification Review and a complete application must be submitted along with the additional documentation supporting the request.

Palmetto GBA
Statistical Analysis Durable Medical Equipment Regional Carrier
Post Office Box 100143 .Columbia. South Carolina. 29202-3143
A CMS Contracted Intermediary and Carrier