Bowel Management Devices

Revision Effective Date: 04/01/2026
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Reference location language for Medicare National Coverage Determinations (NCD) Manual, LCD-related Policy Article, and Medicare Program Integrity Manual (PIM), as clarification
HCPCS CODES:
Added: A4479 to Group 1 Codes


04/16/2026: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates to CMS HCPCS coding determinations.

Revision Effective Date: 10/01/2021
CODING INFORMATION:
Added: HCPCS code A4453, due to quarterly HCPCS code release


12/30/2021: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates to CMS HCPCS coding determinations.

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.

Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Order information as a result of Final Rule 1713
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: Prescriptions (orders) to SWO


02/06/2020: 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.

No changes have been made to this LCD.


04/05/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

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
Added: Denial language for A4553
HCPCS CODES:
Added: HCPCS Code A4553
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
Deleted: Sources of Information
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article

Revision Effective Date 07/01/2016
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed:  Coverage statement for vaginal inserts and related accessories; they are not DME MAC Jurisdiction (Effective date 02/12/2015)
SOURCES OF INFORMATION AND BASIS FOR DECISION:
Removed: Links

Revision Effective Date 07/01/2016
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Added:  Vaginal inserts and accessories information (Effective date 02/12/2015)
HCPCS MODIFIERS:
Deleted:  GA, GZ, GY modifiers DOCUMENTATION REQUIREMENTS:
Revised: Standard documentation language to Orders, revise Proof of delivery instructions, and add Correct coding instructions (Effective date 04/28/2016)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS
Deleted:  GA, GZ, GY modifiers section

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.

Revision Effective Date: 01/01/2016
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Replaced: Miscellaneous HCPCS Code A4335 with new code A4337
HCPCS CODES:
Added: HCPCS Code A4337
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation language to remove start date verbiage from Prescription Requirements (Effective 11/05/2015)

12/01/2015 - Draft LCD promoted to final