A4364 — Adhesive, liquid or equal, any type, per oz
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A completed Standard Written Order (SWO) must be communicated to the supplier before claim submission; for items requiring WOPD the SWO must be signed prior to delivery.
- Suppliers must maintain Proof of Delivery (POD) documentation and make POD available to the Medicare contractor upon request.
- Claims must comply with CMS HCPCS coding guidelines, LCDs, LCD-related Policy Articles, and DME MAC articles; suppliers should follow the LCD-related Standard Documentation Requirements Article and the LCD-related Policy Article and the Supplier Manual for additional documentation requirements.
- Suppliers should refer to DME MAC websites and bulletin articles for additional documentation and payment rule guidance relevant to this LCD.
Key Coverage Criteria
- Facial prosthesis is covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect.
- Any item is covered only if it is in a defined Medicare benefit category and is reasonable and necessary for diagnosis or treatment of illness or injury or to improve functioning of a malformed body member.
- An ostomy supply is covered when it is an eligible Medicare benefit category item, is reasonable and necessary for diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and meets all other applicable Medicare statutory and regulatory requirements.
- Quantity of ostomy supplies is determined based on individual beneficiary factors including ostomy type, ostomy location, ostomy construction, and peristomal skin condition; amounts may vary over time and between beneficiaries.
- Tracheostomy care/cleaning starter kit (HCPCS A4625) is covered following an open surgical tracheostomy for the immediate post-operative period.
- Tracheostomy supplies are covered when they meet Medicare criteria of being in a defined Medicare benefit category and are reasonable and necessary for diagnosis, treatment, or to improve functioning per SSA §1862(a)(1)(A) and other applicable Medicare rules.
4 Active Policies
L33738 — Facial Prostheses
J19
L33828 — Ostomy Supplies
J19
L33832 — Tracheostomy Care Supplies
J19
AETNA-CPB-0526 — Surgical Dressings (Wound Care Supplies)
Related Codes
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