A4455 — Adhesive remover or solvent (for tape, cement or other adhesive), per ounce
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.
- Items are covered if they are in an eligible Medicare benefit category, are reasonable and necessary for diagnosis/treatment or to improve function of a malformed body member, and meet applicable Medicare statutory/regulatory requirements.
- Routine indwelling catheter maintenance: one indwelling catheter unit (e.g., A4314/A4315/A4316/A4340/A4344 variants) per month is covered.
- Non-routine indwelling catheter changes are covered when documentation substantiates medical necessity, including accidental removal, catheter malfunction, obstruction (encrustation/mucous plug/blood clot), or history of recurrent obstruction/UTI requiring scheduled changes >1/month.
- Specialty indwelling catheters (A4340) or all-silicone catheters (A4344, A4312, A4315) are covered when indwelling catheter criteria are met and medical record documents specific need (e.g., recurrent encrustation, inability to pass straight catheter, latex sensitivity).
4 Active Policies
L33738 — Facial Prostheses
J19
L33803 — Urological Supplies
J19
L33828 — Ostomy Supplies
J19
L40270 — Urological Supplies
J19
Related Codes
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