Does A4426 require prior authorization?

No, A4426 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for A4426?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A4426`, Ostomy pouch, drainable; for use on barrier with locking flange (2 piece

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

A completed Standard Written Order (SWO) must be received by the supplier prior to claim submission for items covered by this policy.
For DMEPOS base items that require a Written Order Prior to Delivery (WOPD), a signed WOPD listing the base item (and any associated items, if applicable) must be received prior to delivery.

Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request.

Medical records must document stoma type, ostomy location, ostomy construction, peristomal skin condition, and justification when quantities exceed the usual maximums.

For refills suppliers must contact the beneficiary (or designee), document an affirmative response prior to dispensing a refill, and document the refill request; contact must occur no sooner than 30 calendar days prior to expected end of current supply and delivery no sooner than 10 calendar days prior.

Claims must be coded per CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, and DME MAC articles; supporting coding documentation must be available.

Key Coverage Criteria

An ostomy supply is covered when it is an eligible Medicare benefit category item, is reasonable and necessary for diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and meets all other applicable Medicare statutory and regulatory requirements.
Quantity of ostomy supplies is determined based on individual beneficiary factors including ostomy type, ostomy location, ostomy construction, and peristomal skin condition; amounts may vary over time and between beneficiaries.

1 Active Policy

L33828, Ostomy Supplies

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A4426, Ostomy pouch, drainable; for use on barrier with locking flange (2 piece