Ostomy Supplies

Number: 0906

Policy

Ostomy supplies are considered medically necessary for use on a member with a surgically created opening (stoma) to divert urine, or fecal contents outside the body. Ostomy supplies are considered medically necessary for colostomies, ileostomies or urinary ostomies. 

When a liquid barrier is considered medically necessary, either liquid or spray or individual wipes or swabs are considered medically necessary. The use of both is not considered medically necessary.

The following means to prevent/manage drainage are considered medically necessary for persons with continent stomas: stoma caps, stoma plugs, stoma absorptive covers or gauze pads. No more than one of these types of supply are considered medically necessary on a given day.

Either a bag or bottle are considered medically necessary for drainage at night for members with urinary ostomies. Use of both on a given day is considered not medically necessary.

The medically necessary quantity of ostomy supplies for a member is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual member's need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually considered medically necessary. The actual quantity that is considered medically necessary for a particular member may be more or less than the amount listed depending on the factors that affect the frequency of barrier and pouch change.

The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the member’s medical record. If adequate documentation is not provided when requested, the excess quantities will be considered not medically necessary.

Table: Number per month
Item  Number per month 
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each  2
Skin barrier, solid; 4 X 4 or equivalent; each  20
Adhesive, liquid or equal, any type, per oz.  4
Ostomy belt, each  1
Ostomy skin barrier, liquid (spray, brush, etc.), per oz.   2
Ostomy pouch, drainable,, for use on faceplate, plastic, each  10
Ostomy pouch, urinary, for use on faceplate, plastic, each  10
Irrigation supply, sleeve, each  4
Lubricant, per ounce  4
Ostomy ring, each 10
Ostomy skin barrier, non-pectin based, paste, per ounce 4
Ostomy skin barrier, pectin-based, paste, per ounce 4
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 X 4 inches or smaller, each 20
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 X 4 inches, each 20
Ostomy pouch, closed, with barrier attached, with filter (1 piece), each 60
Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each 60
Ostomy pouch, closed; without barrier attached, with filter (1 piece), each 60
Ostomy pouch, closed, for use on barrier with non-lockeing flange, with filter (2 piece), each 60
Ostomy pouch, closed; ror use on barrier with locking flange (2 piece), each 60
Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each 60
Ostomy pouch, drainable, with barrier attached, with filer (1 piece), each 20
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filer (2 piece system), each 20
Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each 20
Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each 20
Ostomy pouch, urinary, with barrier attached, with build-in convecity, with faucet-type tap with valve (1 piece), each 20
Ostomy pouch, urinary, with barrier attached, with faucet-type tap with valve (1 piece), each 20
Ostomy pouch, urinary, for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each 20
Ostomy pouch, urinary, for use on barrier with locking flange (2 piece), each 20
Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each 20
Tape, non-waterproof, per 18 square inches 40
Tape, waterproof, per 18 square inches 40
Ostomy pouch, closed; with barrier attached (1 piece), each 60
Ostomy pouch, closed; without barrier attached (1 piece), each 60
Ostomy pouch, closed; for use on faceplate, each 60
Ostomy pouch, closed; for use on barrier with flange (2 piece), each 60
Stoma cap 31
Ostomy pouch, drainable, with extended wear barrier attached, with filter (1 piece), each 40
Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter (1 piece), each 40
Ostomy pouch, drainable, with barrier attached (1 piece), each 20
Ostomy pouch, drainable; without barrier attached (1 piece), each 20
Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each 20
Ostomy pouch, urinary; with barrier attached (1 piece), each 20
Ostomy pouch, urinary; without barrier attached (1 piece), each 20
Ostomy pouch, uarinary; for use on barrier with flange (2 piece), each 20
Stoma plug or seal, any type 31
Continent device; catheter for continent stoma 1
Continent device, stoma absorptive cover for continent stoma 150
Ostomy accessory; convex insert 10
Skin barrier; solid, 6 X 6 or equivalent, each 20
Skin barrier; sooid, 8 X 8 or equivalent, each 20
Adhesive or non-adhesive; disk or foam pad 20
Appliance cleaner, incontinence and ostomy appliances, per 16 oz. 1
Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 60
Table: Number per 6 months
Item  Number per 6 months
Ostomy faceplate, each 3
Ostomy skin barrier, powder, per oz. 10
Ostomy irrigation supply; bag, each 2
Ostomy irrigation supply; cone/catheter, with or without brush 2
Adhesive remover or solvent (for tape, cement or other adhesive), per ounce 16
Bedside drainage bottle with or without tubing, rigid or exandable, each 2
Skin barrier, wipes or swabs, each 150

Background

This policy is based upon Medicare DME MAC policy. Medicare considers ostomies as prosthetics.

A solid barrier (wafer) is an interface between the member's skin and the pouching system, has measurable thickness and has an adhesive property. Barriers may be integrated into a "1 piece" pouch, they may be manufactured with a flange and be part of a "2 piece" pouch system (skin barrier with flange), or they may be used independently. usually with a pouch that does not have its own integral skin barrier. An extended wear barrier is a pectin-based barrier with special additives which achieve a stronger adhesive seal, resist breakdown by urine or bowel effluent, permit longer wear times between changes, and normal wear times for those who cannot achieve them with standard barriers.

A barrier with built-in convexity is one in which an outward curve is usually achieved with plastic embedded in the barrier, allowing better protrusion of the stoma and adherence to the skin.

Ostomy skin barriers greater than 4x4 inches refer to the size of the skin barriers themselves, and not to the area of any surrounding tape.

A faceplate is a solid interface between the member’s skin and the pouch. It is usually made of plastic, rubber or encased metal. It does not have an adhesive property and there is no pectin-based or karaya material that is an integral part of a faceplate. It can be taken off the skin and reattached repeatedly. It is secured by means of a separate adhesive and/or an elastic belt. The clips for attaching the belt are usually a part of the faceplate.

A pouch is a device for collecting stomal output. A pouch for collecting bowel effluent may be either "drainable" with an opening at the bottom through which the fecal contents are emptied, or ‘closed’ with a sealed bottom and no outlet. A "urinary" pouch normally incorporates anti-reflux devices and a tap or spigot to empty the urine contents.

A pouch "with barrier attached" is one type of "1 piece" system in which a solid barrier is part of the pouch.

A pouch "without barrier attached" is a pouch with or without a thin adhesive coating that is applied either directly to the skin or to a separate barrier. It is also described as a "1 piece" system.

A pouch, which is part of a "2 piece" system, has a flange, which enables it to be coupled to a skin barrier with flange.

A pouch "with faceplate attached" or "for use on a faceplate" is generally rubber or heavy plastic. It is drainable, cleanable, and reusable for periods of weeks to months, depending on the product.

A "high output" pouch has a capacity of greater than or equal to 0.75 liters, is drainable with a large bore solid spout with cap or plug, and is either part of a 2 piece system or a single-piece system.

Pouches with filters describe pouches that have an opening which allows venting of trapped gas. They typically include materials such as charcoal to deodorize the vented gas..An "ostomy filter, any type, each" describes a replacement filter. 

An "ostomy vent, any type, each" describes a separate ostomy vent that can be added by the member to a pouch to allow the release of gas. An ostomy vent is included in pouches in which a vent with a filter is incorporated in the pouch by the manufacturer. Those products are described as ostomy pouches with a filter.

Absorbent material that is added to the ostomy pouch may come as sheets, pads or crystals.

An ostomy pouch with faucet-type tap with valve has a valve for draining urine.

A locking flange is a lever type flange locking mechanism. It differs from simple push-on pouch securing mechanisms. The mechanism may be incorporated either in the pouch flange or skin barrier flange (2 piece system).

A paste is used as a protective layer and sealant beneath ostomy appliances, and is applied directly on the skin. It may be primarily pectin based, or non-pectin based, e.g., karaya.

Ostomy clamps are used with drainable pouches and are not used with urinary pouches. Ostomy clams are included with osteomy pouches.  Ostomy clamps are only separately payable when ordered as a replacement. .

Appendix

The following table lists faceplate systems. The faceplate components in Column II are included in Column I. When supplying a pouch with faceplate attached (Column I), there is no separate payment for a component product from Column II provided at the same time.

Table: Faceplate systems
Faceplate Systems(Column I) Faceplate Systems(Column II)
Ostomy pouch, drainable, with faceplate attached, plastic, each

Ostomy faceplate, each

Ostomy pouch, drainable, for use on faceplate, plastic, each

Ostomy pouch, drainable, with faceplate attached, rubber, each

Ostomy faceplate, each

Ostomy pouch, drainable, for use on faceplate, rubber, each

Ostomy pouch, urinary, with faceplate attached, plastic, each

Ostomy faceplate, each

Ostomy pouch, urinary, for use on faceplate, plastic, each

Ostomy pouch, urinary, for use on faceplate, heavy plastic, each

Ostomy pouch, urinary, with faceplate attached, rubber, each

Ostomy faceplate, each

Ostomy pouch, urinary, for use on faceplate, rubber, each

Ostomy pouch, closed, with barrier attached, with filter (1 piece), each

Ostomy vent, any type, each

Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each

Ostomy vent, any type, each

Ostomy pouch, closed, without barrier attached, with filter (1 piece), each

Ostomy vent, any type, each

Ostomy pouch, closed, for use on barrier with non-locking  flange, with filter (2 piece), each

Ostomy vent, any type, each

Ostomy pouch, closed, for use on barrier with locking  flange, with filter (2 piece), each

Ostomy vent, any type, each

Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each

Ostomy vent, any type, each

Ostomy pouch, drainable, for use on barrier with non-locking  flange, with filter (2 piece system), each

Ostomy vent, any type, each

Ostomy pouch, drainable, for use on barrier with locking  flange, with filter (2 piece system), each

Ostomy vent, any type, each
Table: CPT Codes / HCPCS Codes / ICD-9 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+" :

HCPCS codes covered if selection criteria are met :

A4331 Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each
A4357 Bedside drainage bag, day or night, with or without antireflux device, with or without tube, eachA
A4361 Bedside drainage bag, day or night, with or without antireflux device, with or without tube, each
A4362 Skin barrier; solid, 4 x 4 or equivalent; each
A4363 Ostomy clamp, any type, replacement only, each
A4364 Adhesive, liquid or equal, any type, per oz
A4366 Ostomy vent, any type, each
A4367 Ostomy belt, each
A4368 Ostomy filter, any type, each
A4369 Ostomy skin barrier, liquid (spray, brush, etc.), per oz
A4371 Ostomy skin barrier, powder, per oz
A4372 Ostomy skin barrier, solid 4 x 4 or equivalent, standard wear, with built-in convexity, each
A4373 Ostomy skin barrier, with flange (solid, flexible or accordian), with built-in convexity, any size, each
A4375 Ostomy pouch, drainable, with faceplate attached, plastic, each
A4376 Ostomy pouch, drainable, with faceplate attached, rubber, each
A4377 Ostomy pouch, drainable, for use on faceplate, plastic, each
A4378 Ostomy pouch, drainable, for use on faceplate, rubber, each
A4379 Ostomy pouch, urinary, with faceplate attached, plastic, each
A4380 Ostomy pouch, urinary, with faceplate attached, rubber, each
A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each
A4382 Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
A4383 Ostomy pouch, urinary, for use on faceplate, rubber, each
A4384 Ostomy faceplate equivalent, silicone ring, each
A4385 Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each
A4387 Ostomy pouch, closed, with barrier attached, with built-in convexity (1 piece), each
A4388 Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each
A4389 Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each
A4390 Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each
A4391 Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each
A4392 Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each
A4393 Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each
A4394 Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fl oz
A4395 Ostomy deodorant for use in ostomy pouch, solid, per tablet
A4396 Ostomy belt with peristomal hernia support
A4397 Irrigation supply; sleeve, each
A4398 Ostomy irrigation supply; bag, each
A4399 Ostomy irrigation supply; cone/catheter, with or without brush
A4402 Lubricant, per oz
A4404 Ostomy ring, each
A4405 Ostomy skin barrier, nonpectin-based, paste, per oz
A4406 Ostomy skin barrier, pectin-based, paste, per oz
A4407 Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 in or smaller, each
A4408 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 x 4 in, each
A4409 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 in or smaller, each
A4410 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 in, each
A4411 Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each
A4412 Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), without filter, each
A4413 Ostomy pouch, drainable, high output, for use on a barrier with flange (2-piece system), with filter, each
A4414 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 in or smaller, each
A4415 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 in, each
A4416 Ostomy pouch, closed, with barrier attached, with filter (1 piece), each
A4417 Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each
A4418 Ostomy pouch, closed; without barrier attached, with filter (1 piece), each
A4419 Ostomy pouch, closed; for use on barrier with nonlocking flange, with filter (2 piece), each
A4420 Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each
A4421 Ostomy supply; miscellaneous
A4422 Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each
A4423 Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each
A4424 Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each
A4425 Ostomy pouch, drainable; for use on barrier with nonlocking flange, with filter (2-piece system), each
A4426 Ostomy pouch, drainable; for use on barrier with locking flange (2-piece system), each
A4427 Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2-piece system), each
A4428 Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each
A4429 Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each
A4430 Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each
A4431 Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each
A4432 Ostomy pouch, urinary; for use on barrier with nonlocking flange, with faucet-type tap with valve (2 piece), each
A4433 Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each
A4434 Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each
A4435 Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each
A4450 Tape, non-waterproof, per 18 sq. in
A4452 Tape, waterproof, per 18 sq. in.
A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per oz
A4456 Adhesive remover, wipes, any type, each
A5051 Ostomy pouch, closed; with barrier attached (1 piece), each
A5052 Ostomy pouch, closed; without barrier attached (1 piece), each
A5053 Ostomy pouch, closed; for use on faceplate, each
A5054 Ostomy pouch, closed; for use on barrier with flange (2 piece), each
A5055 Stoma cap
A5056 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each
A5057 Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each
A5061 Ostomy pouch, drainable; with barrier attached, (1 piece), each
A5062 Ostomy pouch, drainable; without barrier attached (1 piece), each
A5063 Ostomy pouch, drainable; for use on barrier with flange (2-piece system), each
A5071 Ostomy pouch, urinary; with barrier attached (1 piece), each
A5072 Ostomy pouch, urinary; without barrier attached (1 piece), each
A5073 Ostomy pouch, urinary; for use on barrier with flange (2 piece), each
A5081 Stoma plug or seal, any type
A5082 Continent device; catheter for continent stoma
A5083 Continent device, stoma absorptive cover for continent stoma
A5093 Ostomy accessory; convex insert
A5102 Bedside drainage bottle with or without tubing, rigid or expandable, each
A5120 Skin barrier, wipes or swabs, each
A5121 Skin barrier; solid, 6 x 6 or equivalent, each
A5122 Skin barrier; solid, 8 x 8 or equivalent, each
A5126 Adhesive or nonadhesive; disk or foam pad
A5131 Appliance cleaner, incontinence and ostomy appliances, per 16 oz
A6216 Gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without adhesive border, each dressing

ICD-10 codes covered if selection criteria are met :

K94.00 Colostomy complication, unspecified
K94.03 Colostomy malfunction
K94.10 Enterostomy complication, unspecified
K94.13 Enterostomy malfunction
Z43.2 Encounter for attention to ileostomy
Z43.3 Encounter for attention to colostomy
Z43.6 Encounter for attention to other artificial openings of urinary tract
Z93.2 Ileostomy status
Z93.3 Colostomy status
Z93.6 Other artificial openings of urinary tract status

The above policy is based on the following references:

  1. NHIC, Corp. Ostomy Supplies (L33828). DME MAC Jurisdiction A. Hingham, MA: NHIC; effective October 1, 2015. 
  2. NHIC, Corp. Ostomy Supplies - Policy Article.  (A52487). DME MAC Jurisdiction A. Hingham, MA: NHIC; effective October 2015.