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.

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.

The above policy is based on the following references: