Ostomy Supplies - Policy Article - Effective October 2015

Revision Effective Date: 01/01/2022
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: “A permanent ostomy is defined as a condition that is not expected to be medically or surgically corrected in that beneficiary.” and “
Ostomy supplies will be denied as non-covered in situations in which it is expected that the condition will be temporary.”


04/10/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2022
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: “Ostomy supplies are covered for a beneficiary who has a permanent impairment requiring an ostomy. A permanent ostomy is defined as a condition that is not expected to be medically or surgically corrected in that beneficiary. Permanence is a condition that is of a long and indefinite duration. This does not require a determination that there is no possibility that the beneficiary's condition may improve sometime in the future. If the medical record, including the judgment of the treating practitioner, indicates the condition is of long and indefinite duration, the test of permanence is considered met. Ostomy supplies will be denied as non-covered in situations in which it is expected that the condition will be temporary.” as clarification


03/20/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2022
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: “Claims for tape and adhesive (A4450, A4452, A5120) that are billed without an AU modifier or another modifier indicating coverage under a different policy will be rejected as missing information.”
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: “Claims for tape and adhesive (A4450, A4452, A5120) that are billed without an AU modifier or another modifier indicating coverage under a different policy will be rejected as missing information.”
Removed: “Claims lines for A4450, A4452 and A5120 billed without AU modifier will be rejected as missing information.”


05/04/2023: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2022
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list
CODING GUIDELINES:
Added: Code description for HCPCS codes A4436 and A4437


04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2022
CODING GUIDELINES:
Added: Billing direction regarding codes A4436 and A4437 (valid for billing on or after DOS 01/01/2022)
Removed: Code A4397 (invalid for billing on or after DOS 01/01/2022)


12/30/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Continued medical need language


06/04/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination

Revision Effective Date: 01/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
 CODING GUIDELINES:

Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


02/20/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination

02/07/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This is an article and not a local coverage determination.

Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Billing Directions
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Standard Documentation Language article

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Revision Effective Date: 08/01/2015
NON-MEDICAL NECESSITY AND PAYMENT RULES:
Removed: ICD-9 references
Revised: Language for HCPCS codes A4450, A4452, A5120 when submitted without correct modifier