369 Form

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Medical Policy
Ostomy Supplies Table of Contents • Policy: Commercial • Policy History • Information Pertaining to All Policies
• Authorization Information • References • Endnotes • Coding Information

Policy Number: 369 BCBSA Reference Number: N/A Related Policies
None Policy1 Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

The quantity of ostomy supplies needed by a member is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual member need and their needs may vary over time.

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 the factors that affect the frequency of barrier and pouch change.

The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the member’s medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as NOT MEDICALLY NECESSARY.

Usual Maximum Quantity of Supplies Code Description Number per month A4357 Bedside drainage bag, day or night, with or without antireflux device, with or without tube, each 2 A4362 Skin barrier; solid, 4 x 4 or equivalent; each 20 A4364 Adhesive, liquid or equal, any type, per oz 4 A4367 Ostomy belt, each 1 A4369 Ostomy skin barrier, liquid (spray, brush, etc.), per oz 2 A4377 Ostomy pouch, drainable, for use on faceplate, plastic, each 10 A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each 10 A4402 Lubricant, per oz 4 A4404 Ostomy ring, each 10 A4405 Ostomy skin barrier, nonpectin-based, paste, per oz 4 A4406 Ostomy skin barrier, pectin-based, paste, per oz 4

2 A4414 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 in or smaller, each 20 A4415 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 in, each 20 A4416 Ostomy pouch, closed, with barrier attached, with filter (one piece), each 60 A4417 Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (one piece), each 60 A4418 Ostomy pouch, closed; without barrier attached, with filter (one piece), each 60 A4419 Ostomy pouch, closed; for use on barrier with nonlocking flange, with filter (two piece), each 60 A4420 Ostomy pouch, closed; for use on barrier with locking flange (two piece), each 60 A4423 Ostomy pouch, closed; for use on barrier with locking flange, with filter (two piece), each 60 A4424 Ostomy pouch, drainable, with barrier attached, with filter (one piece), each 20 A4425 Ostomy pouch, drainable; for use on barrier with nonlocking flange, with filter (two-piece system), each 20 A4426 Ostomy pouch, drainable; for use on barrier with locking flange (two-piece system), each 20 A4427 Ostomy pouch, drainable; for use on barrier with locking flange, with filter (two-piece system), each 20 A4429 Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (one piece), each 20 A4431 Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (one piece), each 20 A4432 Ostomy pouch, urinary; for use on barrier with nonlocking flange, with faucet-type tap with valve (two piece), each 20 A4433 Ostomy pouch, urinary; for use on barrier with locking flange (two piece), each 20 A4434 Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (two piece), each 20 A4436 Irrigation supply; sleeve, reusable, per month 1 A4437 Irrigation supply; sleeve, disposable, per month 1 A4450 Tape, nonwaterproof, per 18 sq in 40 A4452 Tape, waterproof, per 18 sq in 40 A5051 Ostomy pouch, closed; with barrier attached (one piece), each 60 A5052 Ostomy pouch, closed; without barrier attached (one piece), each 60 A5053 Ostomy pouch, closed; for use on faceplate, each 60 A5054 Ostomy pouch, closed; for use on barrier with flange (two piece), each 60 A5055 Stoma cap 31 A5056 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (one piece), each 40 A5057 Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (one piece), each 40 A5061 Ostomy pouch, drainable; with barrier attached, (one piece), each 20 A5062 Ostomy pouch, drainable; without barrier attached (one piece), each 20

3 A5063 Ostomy pouch, drainable; for use on barrier with flange (two- piece system), each 20 A5071 Ostomy pouch, urinary; with barrier attached (one piece), each 20 A5072 Ostomy pouch, urinary; without barrier attached (one piece), each 20 A5073 Ostomy pouch, urinary; for use on barrier with flange (two piece), each 20 A5081 Stoma plug or seal, any type 31 A5082 Continent device; catheter for continent stoma 1 A5083 Continent device, stoma absorptive cover for continent stoma 150 A5093 Ostomy accessory; convex insert 10 A5121 Skin barrier; solid, 6 x 6 or equivalent, each 20 A5122 Skin barrier; solid, 8 x 8 or equivalent, each 20 A5126 Adhesive or nonadhesive; disk or foam pad 20 A6216 Gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without adhesive border, each dressing 60

Code Description Number per 6 months A4361 Ostomy faceplate, each 3 A4371 Ostomy skin barrier, powder, per oz 10 A4398 Ostomy irrigation supply; bag, each 2 A4399 Ostomy irrigation supply; cone/catheter, with or without brush 2 A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per oz 16 A5102 Bedside drainage bottle with or without tubing, rigid or expandable, each 2 A5120 Skin barrier, wipes or swabs, each 150

When a liquid barrier is MEDICALLY NECESSARY, either liquid OR spray (A4369) OR individual wipes OR swabs (A5120) are appropriate. The use of both is NOT MEDICALLY NECESSARY.

Members with continent stomas may use the following means to prevent/manage drainage: • Stoma cap (A5055) • Stoma plug (A5081) • Stoma absorptive cover (A5083) OR
• Gauze pads (A6216).
No more than one of these types of supply would be reasonable and necessary on a given day.

Members with urinary ostomies may use either:
• Bag (A4357) OR
• Bottle (A5102) for drainage at night.
It is not reasonable and necessary to have both.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient

4 Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

HCPCS Codes HCPCS codes:

Code Description A4331 Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each A4357 Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each A4361 Ostomy faceplate, each A4362 Skin barrier; solid, 4 x 4 or equivalent; each A4363 Ostomy clamp, any type, replacement only, each A4364 Adhesive, liquid or equal, any type, per oz A4366 Ostomy vent, any type, each A4367 Ostomy belt, each A4368 Ostomy filter, any type, each A4369 Ostomy skin barrier, liquid (spray, brush, etc.), per oz A4371 Ostomy skin barrier, powder, per oz A4372 Ostomy skin barrier, solid 4 x 4 or equivalent, standard wear, with built-in convexity, each A4373 Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each A4375 Ostomy pouch, drainable, with faceplate attached, plastic, each A4376 Ostomy pouch, drainable, with faceplate attached, rubber, each A4377 Ostomy pouch, drainable, for use on faceplate, plastic, each A4378 Ostomy pouch, drainable, for use on faceplate, rubber, each A4379 Ostomy pouch, urinary, with faceplate attached, plastic, each A4380 Ostomy pouch, urinary, with faceplate attached, rubber, each A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each A4382 Ostomy pouch, urinary, for use on faceplate, heavy plastic, each A4383 Ostomy pouch, urinary, for use on faceplate, rubber, each A4384 Ostomy faceplate equivalent, silicone ring, each A4385 Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each A4387 Ostomy pouch, closed, with barrier attached, with built-in convexity (1 piece), each A4388 Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each A4389 Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each

5 A4390 Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each A4391 Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each A4392 Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each A4393 Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each A4394 Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce A4395 Ostomy deodorant for use in ostomy pouch, solid, per tablet A4396 Ostomy belt with peristomal hernia support A4397 irrigation supply; sleeve, each A4398 Ostomy irrigation supply; bag, each A4399 Ostomy irrigation supply; cone/catheter, with or without brush A4402 Lubricant, per ounce A4404 Ostomy ring, each A4405 Ostomy skin barrier, non-pectin based, paste, per ounce A4406 Ostomy skin barrier, pectin-based, paste, per ounce A4407 Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built- in convexity, 4 x 4 inches or smaller, each A4408 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 x 4 inches, each A4409 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each A4410 Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 inches, each A4411 Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each A4412 Ostomy pouch, drainable, high output, for use on a barrier with flange (2-piece system), without filter, each A4413 Ostomy pouch, drainable, high output, for use on a barrier with flange (2-piece system), with filter, each A4414 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each A4415 Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 inches, each A4416 Ostomy pouch, closed, with barrier attached, with filter (1 piece), each A4417 Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each A4418 Ostomy pouch, closed; without barrier attached, with filter (1 piece), each A4419 Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each A4420 Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each A4421 Ostomy supply; miscellaneous A4422 Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each A4423 Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each A4424 Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each A4425 Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2-piece system), each A4426 Ostomy pouch, drainable; for use on barrier with locking flange (2-piece system), each A4427 Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2-piece system), each

6 A4428 Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each A4429 Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each A4430 Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each A4431 Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each A4432 Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each A4433 Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each A4434 Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each A4435 Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each A4450 Tape, non-waterproof, per 18 square inches A4452 Tape, waterproof, per 18 square inches A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per ounce A4456 Adhesive remover, wipes, any type, each A5051 Ostomy pouch, closed; with barrier attached (1 piece), each A5052 Ostomy pouch, closed; without barrier attached (1 piece), each A5053 Ostomy pouch, closed; for use on faceplate, each A5054 Ostomy pouch, closed; for use on barrier with flange (2 piece), each A5055 Stoma cap A5056 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each A5057 Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each A5061 Ostomy pouch, drainable; with barrier attached, (1 piece), each A5062 Ostomy pouch, drainable; without barrier attached (1 piece), each A5063 Ostomy pouch, drainable; for use on barrier with flange (2-piece system), each A5071 Ostomy pouch, urinary; with barrier attached (1 piece), each A5072 Ostomy pouch, urinary; without barrier attached (1 piece), each A5073 Ostomy pouch, urinary; for use on barrier with flange (2 piece), each A5081 Stoma plug or seal, any type A5082 Continent device; catheter for continent stoma A5083 Continent device, stoma absorptive cover for continent stoma A5093 Ostomy accessory; convex insert A5102 Bedside drainage bottle with or without tubing, rigid or expandable, each A5120 Skin barrier, wipes or swabs, each A5121 Skin barrier; solid, 6 x 6 or equivalent, each A5122 Skin barrier; solid, 8 x 8 or equivalent, each A5126 Adhesive or non-adhesive; disk or foam pad A5131 Appliance cleaner, incontinence and ostomy appliances, per 16 oz. A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing A9270 Non-covered item or service

Policy History Date Action 1/2022 Removed code A4397 from Usual Maximum Quantity of Supplies table. Added codes A4436 and A4437 to Usual Maximum Quantity of Supplies table. Effective 1/1/2022.

7 10/2021 New medical policy describing medically necessary and not medically necessary ostomy supplies. Effective 10/1/2021. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References N/A

Endnotes

1 Based on Local Coverage Determination (LCD): Ostomy Supplies L33828 Local Coverage Article: Ostomy Supplies - Policy Article A52487