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Every policy word on this page is CMS's own. Verzi adds pins, receipts, and links only.

A4559

Osteogenesis Stimulators

LCD L33796 · CMS's HCPCS descriptor for A4559: Coupling gel or paste, for use with ultrasound device, per oz.

Not on CMS's Required Prior Authorization List for DMEPOS on 2026-10-13. source

LCD L33796 · 9 versions, 2015 to today · last changed 2024-01-01 (R8)

Version 6 of LCD L33796: in force by CMS's dates 2015-10-01 to 2016-06-30. The policy text on this page comes from this archived version.

DME MAC jurisdictions
JA · Noridian 16013
CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, VT
JB · CGS 17013
IL, IN, KY, MI, MN, OH, WI
JC · CGS 18003
AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, VI, VA, WV
JD · Noridian 19003
AK, AS, AZ, CA, GU, HI, ID, IA, KS, MO, MT, NE, NV, ND, MP, OR, SD, UT, WA, WY
source

CMS's Who are the MACs jurisdiction pages (DME facts as of 2025-09-30) name each contractor and its states; the MCD's Contractor Information table on every DME LCD prints the contract numbers. Both read 2026-10-09. Verzi adds the state lookup only.

You are viewing version 6 (2015-10-01 to 2016-06-30). Version 24 is in force today.

Codes CMS lists in this LCD's current version (version 24, 4 codes). CMS's download carries no list for version 6: A4559 E0747 E0748 E0760

Sections in this version: CMS National Coverage Policy · Coverage Indications, Limitations, and/or Medical Necessity · Coding Information · Associated Information · Sources of Information and Basis for Decision. Plus 3 sections marked N/A in this version.

Full verbatim text serves to customers · Customer? Log in

Version history, LCD L33796

CMS numbers each version. Each box shows the version's window by CMS's stated dates. Select a version to show it on this page. Versions superseded the same day they took effect never governed a claim, so the page hides them until you ask. Version numbers CMS never published to its archive do not exist as documents.

Revision history, every version

CMS's own change log, quoted, 8 entries. It does not change with the version shown. A revision (R-number) is a change CMS logged. The version (vN) is the snapshot that carries it.

R8 · 2024-01-01 · v24
Revision Effective Date: 01/01/2024
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Added: “and document an affirmative response” to language that pertains to contact with the beneficiary or caregiver/designee for DMEPOS products supplied as refills
Revised: “approaching exhaustion” to “expected to end” in regard to existing supplies
Revised: “Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date.” to “Contact with the beneficiary or designee regarding refills must take place no sooner than 30 calendar days prior to the expected end of the current supply.”
Revised: “For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product.” to “For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the expected end of the current supply.”


12/14/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates to refill requirement information per CMS Final Rule CMS-1780-F.
R7 · 2023-07-02 · v21
Revision Effective Date: 07/02/2023
SUMMARY OF EVIDENCE:
Added: Information related to GA, GZ, and KX modifier addition
ANALYSIS OF EVIDENCE:
Added: Information related to GA, GZ, and KX modifier addition
CODING INFORMATION:
Added: GA, GZ and KX modifiers
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments (A59402)
R6 · 2020-01-01 · v17
Revision Effective Date: 01/01/2020
CODING INFORMATION:
Removed: Field titled “Bill Type”
 Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
As required by CR 10901, the ICD-10 information has been moved to all Policy Articles. There is no change in coverage.
R5 · 2020-01-01 · v15
Revision Effective Date: 01/01/2020

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
 Revised: “physician” to “treating practitioner”
 GENERAL:
 Revised: Order information as a result of Final Rule 1713
 REFILL REQUIREMENTS:
 Revised: “ordering physicians” to “treating practitioners”
 HCPCS MODIFIERS:
 Revised: Typographical error for definition of EY modifier “sevice” to “service”
 DOCUMENTATION REQUIREMENTS:
 Revised: “physician’s” to “treating practitioner’s”
 GENERAL DOCUMENTATION REQUIREMENTS:
 Revised: “Prescriptions (orders)” to “SWO”


02/13/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713.
R4 · 2017-01-01 · v10
Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
Revised: Refill Requirements
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Supplier Manual reference from Miscellaneous section
Removed: PIM reference under Appendices section
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article
R3 · 2016-07-01 · v8
Effective July 1, 2016 oversight for DME MAC LCDs 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 LCDs.
R2 · 2015-10-01 · v6
Revision Effective Date: 10/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: References to ICD-10 Codes
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Deleted: ICD-10 Codes
R1 · 2015-10-01 · v4
Revision Effective Date: 10/31/2014
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation Language to add who can enter date of delivery date on the POD
Added: Instructions for Equipment Retained from a Prior Payer
Added: Repair/Replacement section
Receipts for auditors

Version 6 of LCD L33796, shown on this page: in force by CMS's dates 2015-10-01 to 2016-06-30. Archived 2026-09-26. CMS's copy · Our archived file. 8 of 8 sections are proven word-identical to the archived file.

Every archived version of LCD L33796 (9 versions, CMS's dates, window by the as-of rule). The Article rows are the Article versions in force on the start dates of these LCD versions.

DocumentVersionIn forceArchived onVerify
LCD L33796version 22015-10-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33796version 42015-10-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33796version 6 shown2015-10-01 to 2016-06-302026-09-26CMS's copy · Our archived file
LCD L33796version 82016-07-01 to 2016-12-312026-09-26CMS's copy · Our archived file
LCD L33796version 102017-01-01 to 2019-12-312026-09-26CMS's copy · Our archived file
LCD L33796version 152020-01-01, superseded same day2026-09-26CMS's copy · Our archived file
LCD L33796version 172020-01-01 to 2023-07-012026-09-26CMS's copy · Our archived file
LCD L33796version 212023-07-02 to 2023-12-312026-09-26CMS's copy · Our archived file
LCD L33796version 242024-01-01 to today2026-09-26CMS's copy · Our archived file
Article A52513version 32015-10-01 to 2016-06-302026-09-26CMS's copy · Our archived file
Article A52513version 42016-07-01 to 2016-12-312026-09-26CMS's copy · Our archived file
Article A52513version 132017-01-01 to 2019-12-312026-09-26CMS's copy · Our archived file
Article A52513version 232020-01-01 to 2022-12-312026-09-26CMS's copy · Our archived file
Article A52513version 432023-07-02 to 2026-05-172026-10-09CMS's copy · Our archived file
Article A55426version 122017-01-01 to 2017-04-192026-09-26CMS's copy · Our archived file
Article A55426version 722020-01-01 to 2020-04-052026-09-26CMS's copy · Our archived file
Article A55426version 1032023-01-01 to 2023-12-312026-09-26CMS's copy · Our archived file
Article A55426version 1322024-01-01 to today2026-09-26CMS's copy · Our archived file

Each archived file's page gives its sha256 fingerprint. A copy of the file hashes to the same value, byte for byte.

CMS's live page shows only the current version. To check a passage by eye, open CMS's copy of the same version number. A version's window ends on the earlier of CMS's stated end date and the day before the next version starts.

Every policy word on this page is CMS's, from the archived version named beside it. Verzi adds labels, highlights, citations and links only. Verzi-written summary content on this page: none.

Governing policies, as CMS lists them:

  • LCD L33796 · Osteogenesis Stimulators
    CMS lists A4559 in group 2 of version 24. CMS's description, quoted: “COUPLING GEL OR PASTE, FOR USE WITH ULTRASOUND DEVICE, PER OZ”.
    Related Articles, as CMS lists them: Article A59402 · Article A55426 · Article A52513

From CMS's LCD code table. HCPCS Level II codes only.

source

CMS's LCD code table in the Medicare Coverage Database download, archived 2026-10-09: Our archived file.

Watch A4559

One email when any policy cited for A4559 changes or gains a future effective date. Nothing else, ever.