Covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
A Standard Written Order (SWO) must be received by the supplier before a claim is submitted for items addressed in this policy.
For DMEPOS items requiring WOPD, the supplier must have a signed SWO/WOPD before delivery; WOPD may list the base item and associated separately billed options/supplies.
Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request.
For refills, suppliers must contact the beneficiary (no sooner than 30 days before expected end) and document an affirmative response prior to dispensing; delivery may occur no sooner than 10 days before expected end.
If a beneficiary requires quantities greater than the usual maximum, the clinical justification and explanation for the greater quantity must be clearly documented in the beneficiary's medical record.
Key Coverage Criteria
Tracheostomy care/cleaning starter kit (HCPCS A4625) is covered following an open surgical tracheostomy for the immediate post-operative period.
Tracheostomy supplies are covered when they meet Medicare criteria of being in a defined Medicare benefit category and are reasonable and necessary for diagnosis, treatment, or to improve functioning per SSA §1862(a)(1)(A) and other applicable Medicare rules.