Tracheostomy Supplies Form

This policy is based upon Medicare DME MAC policy. Medicare considers a tracheostomy as a prosthetic.

Medicare covers supplies for care of a tracheostomy site for persons following an open surgical tracheostomy which has been open or is expected to remain open for at least 3 months.

A tracheostomy collar/holder is used to secure the tracheostomy tube's positioning, minimize movement of the tracheostomy tube and reduce the risk of cannula disruption or decannulation. Fastener tabs attach to the tracheostomy tube to hold the collar in place.

Note

: A tracheostomy tube collar/holder should not be billed for twill ties, or twill tape or equivalent fabric or plastic supplies.

Heat/Moisture Exchangers (HME) are a type of stoma cover which help laryngectomees partially restore functions previously performed by the nose and upper airway. During exhalation, warmth and humidity are conveyed from the lungs and deposited into the filter. During inhalation, the warmth and moisture are picked back up by incoming air and returned to the lungs.

HME consist of a plastic cassette/holder that contains a filter. The holder fits into a plastic housing which is held in place over the tracheostoma by adhesive. An HME may be used by itself or in addition to a tracheostoma valve.

A tracehostoma filter is a small filter usually having adhesive along one edge which is attached to the skin and simply covers the tracheostoma to keep large piece of debris out. It is not an HME.

Moisture exchanger, disposable, for use with invasive mechanical ventilation is a moisture exchanger that is used only with an invasive mechanical ventilator; it is not an HME over a tracheostoma.

A reusable filter holder or filter cap for use in a trachostoma heat and moisture exchange system is a device that connects to the tracheostoma cassette and holds an HME filter. The holder/cap can open and close to replace the HME filter.

A filter for use in a trachostoma heat and moisture exchange system is a filter that fits into a reusable filter holder or filter cap for use in a trachostoma HME system.

An adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve is a double sided adhesive disc that attaches the HME cassette to the member’s skin.

A filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system is an integrated filter and holder that utilizes an adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve to fit over the tracheostomy or may utilize liquid adhesive on both sides of the cassette to attach the HME to the member.

A housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve is integrated housing and adhesive used with either an HME or tracheostoma valve.

A filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system is the integrated filter holder and housing used with the HME system.

A tracheostomy valve with diaphragm is a device used over the tracheostomy stoma by a member who has had the larynx removed and has a trachealesophageal voice prosthesis, but does not have a tracheostomy tube.

A tracheostomy care or cleaning starter kit is provided in the first 2 post-operative weeks, and contains the following:

1 plastic tray

1 basin

1 pair sterile gloves

1 tube brush

3 pipe cleaners

1 pre-cut tracheostomy dressing

1 roll gauze

4 4x4 sponges

2 cotton tip applicators

30 inches twill tape.

A tracheostomy care kit for an established tracheostomy is provided after the first 2 post-operative weeks, and contains the following:

1 tube brush

2 pipe cleaners

2 cotton tip applicators

30 inches twill tape

2 4x4 sponges.

Tracheostomy care kits for new or established tracheostomy includes a tracheostomy cleaning brush.

Scope of Policy

This Clinical Policy Bulletin addresses tracheostomy supplies.

Medical Necessity

Aetna considers supplies for care of a tracheostomy site medically necessary for a member following an open surgical tracheostomy which has been open or is expected to remain open for at least three months.

Aetna considers a tracheostomy care or cleaning starter kit medically necessary following an open surgical tracheostomy. Beginning two weeks post-operatively, a tracheostomy care or cleaning starter kit is no longer considered medically necessary.

A tracheostomy shower protector is a convenience item and therefore considered not medically necessary. A tracheostomy/laryngectomy tube plug/stop is used as an alternative to a tracheostomy/laryngectomy tube and therefore for a member receiving a tracheostomy/laryngectomy tube plug/stop, a tracheostomy/laryngectomy tube is considered not medically necessary. The quantities of supplies included in a tracheostomy care kit are to provide all necessary quantities for the care of the tracheostomy site; additional quantities of tracheostomy supplies are considered not medically necessary. Additional supplies may be considered medically necessary only for care other than for a tracheostomy site, such as for speaking valves.

The table below lists the maximum number of items/units of service that are usually medically necessary. The actual quantity needed for a particular member may be more or less than the amount listed depending on clinical factors that affect the frequency of supply changes. The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the member’s medical record.

Table: Usual Medically Necessary Quantity of Supplies Item Number per month (unless noted) Adhesive, liquid or equal, any type, per oz. 4 Lubricant, per ounce 4 Tape, non-waterproof, per 18 square inches 40 Tape, waterproof, per 18 square inches 40 Adhesive remover, wipes, any type, each 50 Tracheostoma filter, any type, any size, each 62 Tracheostomy, inner cannula 62 Tracheostomy care kit for new tracheostomy 31 Tracheostomy cleaning brush, each 2 Tracheostomy care kit for established tracheostomy 31 Skin barrier, wipes or swabs, each 150 Tracheostoma valve, including diaphragm, each 1 Replacement diaphragm/faceplate for tracheostoma valve, each 1 Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each 1 per 6 months Filter for use in a trachostoma heat and moisture exchange system, each 62 Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each 2 per 3 months Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type, each 62 Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each 62 Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each 62 Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each 62 Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (PVC), silicone or equal, each 1 per 3 months Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each 1 per 3 months Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each 1 per 12 months Tracheostoma stent/stud/button, each 1 per 3 months Tracheostomy tube collar/holder, each 31 Tracheostomy/laryngectomy tube plug/stop, each 2 per 3 months