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Home > Medicare Recipient Programs > Ostomy Supplies > Rules

 Ostomy Supplies

Medicare Part B Coverage Rules and Limitations
  1. Medicare Guidelines for Ostomy Supplies
    Note: Monthly allowable amounts do not represent a benefit limit. The actual quantity needed by a particular customer may be more or less than the amount listed, depending on the individual customer's medical condition. Customers ordering over the allowable amount must have appropriate medical justification (i.e. a letter of medical necessity)
Effective 01/01/2003 Quantity Limitations BLN Assignment?
Adhesives and Adhesive Removers  
Adhesive (Cement), Liquid Or Equal, Any Type, Per Oz (A4364) 4 oz per month Assignment on Formulary Products Only
Adhesive Remover Or Solvent (For Tape, Cement Or Other Adhesive), Per Ounce (A4455) 8 oz per 3 months
16 oz per 6 months		 Assignment on Formulary Products Only
Adhesive Or Non-Adhesive; Disk Or Foam Pad (A5126) 20 per month Assignment on Formulary Products Only
Pouches  
Ostomy Pouch, Closed (A5051, A5052, A5053, A5054) Up to 60 needs documentation
Ostomy Pouch, Drainable - 2 piece (A5063) Up to 20 Assignment on Formulary Products Only
Ostomy Pouch, Drainable - 1 piece (A5062, K0567, K0568) Up to 20 Assignment on Formulary Products Only
Ostomy Pouch, Urinary, For Use On Faceplate, Plastic, Each (A4381) 10 per month Assignment on Formulary Products Only
Ostomy Pouch, Urinary - 2 piece (A5073) 20 per month Assignment on Formulary Products Only
Ostomy Pouch, Urinary - 1 piece (A5071, A5072) 20 per month Assignment on Formulary Products Only
Wafers/Flanges   Assignment on Formulary Products Only
Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion) (K0570, K0571, A4414, A4415) 20 per month Assignment on Formulary Products Only
Skin Barrier; Solid, 4"x4", 6"x6", or 8"x8" (A4362, A5121, A5122) 20 per month Assignment on Formulary Products Only
Skin Barriers  
Ostomy Skin Barrier, Liquid (Spray, Brush, Etc), Per Oz (A4369) 2 oz per month Assignment on Formulary Products Only
Ostomy Skin Barrier, Paste, Per Ounce (K0561, K0562, A4405, A4406) 4 oz per month No Assignment
Ostomy Skin Barrier, Powder, Per Oz (A4371) 5 oz per 3 months
10 oz per 6 months		 Assignment on Formulary Products Only
Other    
Appliance Cleaner, Incontinence And Ostomy Appliances, Per 16 Oz. (A5131) 16 oz per month Assignment on Formulary Products Only
Bedside Drainage Bag, Day Or Night, With Or Without Anti-Reflux Device, With or Without Tube, Each (A4357) 2 ea per month Assignment on Formulary Products Only
Bedside Drainage Bottle With Or Without Tubing, Rigid Or Expandable, Each (A5102) 1 ea every 3 months
2 ea every 6 months		 No Assignment
Belt, Ostomy (A4367) 1 ea every 3 months
2 ea every 6 months		 No Assignment
Belt, Ostomy (A4367) 1 ea per month Assignment on Formulary Products Only
Continent Device; Catheter For Continent Stoma (A5082) 1 per month Assignment on Formulary Products Only
Continent Device; Plug For Continent Stoma (A5081) 31 per month Assignment on Formulary Products Only
Gauze, Non-Impregnated, Non-Sterile, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing (A6216) 60 per month Assignment on Formulary Products Only
Irrigation Supply; Sleeve, Each (A4397) 4 per month Assignment on Formulary Products Only
Lubricant, Per Ounce (A4402) 4 oz per month Assignment on Formulary Products Only
Ostomy Accessory; Convex Insert (A5093) 10 per month Assignment on Formulary Products Only
Ostomy Faceplate, Each (A4361) 3 per 6 months Assignment on Formulary Products Only
Ostomy Irrigation Supply; Bag, Each (A4398) 2 per 6 months Assignment on Formulary Products Only
Ostomy Ring, Each (A4404) 10 per month Assignment on Formulary Products Only
Stoma Cap (A5055) 31 per month Assignment on Formulary Products Only
Tape, per 18 Square Inches (A4450, A4452) Varies by region.
Approx. 2 rolls of 1" tape per month		 No Assignment
NON-COVERED ITEMS Pouch covers
Liquid barriers and wipes in the same month
Stoma caps, plugs, or gauze, not all three
A urinary bag or bottle for the night, not both
Quantities in excess of the guidelines unless accompanied by a doctor's letter explaining the necessity for additional supplies.
*Please note that Medicare will pay for a
3-month supply of Ostomy products at one time.

Better living Now, Inc. assumes no responsibility in regards to Medicare coverage and has interpreted Medicare Rules for the benefit and understanding of the patient. For detailed information regarding Medicare coverage please visit their web site at: www.cms.gov. For Coverage Information for Ostomy Supplies go to: http://www.tricenturion.com/content/dmerc/0602_16_10_ostomy_supplies.cfm




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