A4417 — Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each
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 received by the supplier prior to claim submission for items covered by this policy.
- For DMEPOS base items that require a Written Order Prior to Delivery (WOPD), a signed WOPD listing the base item (and any associated items, if applicable) must be received prior to delivery.
- Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request.
- Medical records must document stoma type, ostomy location, ostomy construction, peristomal skin condition, and justification when quantities exceed the usual maximums.
Key Coverage Criteria
- 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.
1 Active Policy
L33828 — Ostomy Supplies
J19
Related Codes
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