Ostomy Supplies

Ostomy Supplies

Ostomy supplies are covered by Medicare and most private Insurance(depending on coverage) so long as your doctor writes a prescription for these items, and you receive them from a medical supplier that accepts Medicare and/or insurance payments.

Understanding Medicare’s Coverage of Ostomy Supplies

Medicare covers ostomy supplies if you have a surgically created opening, or stoma, to divert urine or stool to outside your body.

These medically necessary supplies are covered by Medicare if you’ve undergone certain surgeries, including a colostomy, ileostomy or urinary ostomy.

You must have a prescription, signed and dated by your doctor, on file with the supplier who provides your ostomy materials.

You can order ostomy supplies from trusted durable medical equipment store , GoodHope Home Healthcare Inc.

You generally can’t get ostomy supplies from a local drugstore or retail pharmacy.

Cost of Ostomy Supplies

Ostomy supplies are covered by Medicare Part B as durable medical equipment. Specifically, these items are considered prosthetics because they replace a body organ or organ function.

You may pay less for your ostomy supplies if you have supplemental insurance, such as Medicaid or a Medigap policy.

Medicare Advantage plans, which are administered by private insurers that contract with the federal government, must provide the same basic coverage as Original Medicare.

However, if you’re enrolled in a Medicare Advantage plan, there may be additional benefits or criteria you must follow to order your supplies.

Make sure to contact your Medicare Advantage plan’s customer service department to learn about such details before ordering your supplies.

How Many Ostomy Supplies Can You Receive with Medicare?

The list of covered Medicare ostomy supplies is long.

The quantity and kind of supplies you need depends on the type of ostomy surgery you undergo.

The U.S. Centers for Medicare & Medicaid Services, or CMS, has determined standard quantities of ostomy supplies each beneficiary can receive.

Medicare may cover more items if your doctor clearly documents a need for additional supplies in your medical record.

Otherwise, Medicare may deny excess quantities If adequate documentation is not provided when requested.

The table below shows the maximum number of items typically considered medically necessary for certain common ostomy products. This is not an exhaustive list.

Ostomy Supplies Covered by Medicare, By Type and Quantity

Code Description Usual Medicare Maximum Quantities
A4357 Bedside drainage bag 2 per month
A4362 Solid skin barrier 4×4 inches 20 per month
A4367 Ostomy belt 1 per month
A4368 Ostomy pouch filter, any type No maximum listed
A4369 Skin barrier, liquid or spray, per ounce 2 ounces per month
A4371 Skin barrier, powder, per ounce 10 ounces every 6 months
A5102 Bedside drainage bottle with or without tubing, rigid or expandable No maximum listed
A4388 Ostomy drainable pouch with extended wear barrier No maximum listed
A4389 Ostomy drainable pouch with a barrier, convex No maximum listed
A4394 Ostomy pouch liquid deodorant 8 ounces per month
A5120 Skin barrier wipes or swabs 150 each, every 6 months
A5073 Urinary pouch for use on barrier with flange, two-piece 20 for each piece every month
A5057 Ostomy drainable pouch with extended wear barrier, convex, filter, one-piece 40 per month
A4396 Support belt No maximum listed
A4404 Ostomy ring 10 per month
A4405 Ostomy paste (non-pectin based) 4 ounces per month
A4406 Ostomy paste (pectin based) 4 ounces per month
A5071 Urinary pouch with barrier 20 per month
A5063 Ostomy drainable pouch with flange, non-filter 20 per month
A5061 Ostomy drainable pouch with barrier attached; one piece 20 per month
A5056 Ostomy drainable pouch with extended wear barrier, filter, one-piece 40 per month
A4407 Skin barrier with flange, extended-wear, convex (4×4 inches or smaller) No maximum listed
A4409 Skin barrier with flange, extended wear (4×4 inches or smaller) No maximum listed
A5055 Stoma cap 31 per month
A4412 HOPO w filter > 750ML No maximum listed
A4413 HOPO w filter > 750ML No maximum listed
A4414 Skin barrier with flange, standard wear (4×4 inches or smaller) 20 per month
A4415 Ostomy standard wear skin barrier greater than 4×4 inches 20 per month
A4416 Ostomy closed-end pouch with filter 60 per month
A4417 Ostomy closed-end pouch with a barrier, convex, filter, one-piece 60 per month
A4419 Ostomy closed-end pouch with filter on non-locking system 60 per month
A4423 Ostomy closed end pouch for locking system, with filter 60 per month
A4424 Ostomy drainable pouch with barrier, filter, one-piece 20 per month
A4433 Ostomy urinary pouch for locking system 20 per month
A4425 Ostomy drainable pouch for non-locking system, with filter 20 per month
A4427 Ostomy drainable pouch for locking system, with filter 20 per month

NOTE: In some situations, Medicare may restrict coverage for the type of ostomy supplies you can order.

What If Medicare Denies Your Ostomy Supply Claim?

Getting the medically necessary ostomy products you need can be tricky unless you follow certain Medicare rules and procedures.

When you are being discharged from the hospital to your home following ostomy surgery, your doctor should send the prescription for your supplies to a supply distributor approved by Medicare.

This prescription will include your list of ostomy supplies, amount, and manufacturer reference numbers.

If Medicare denies your claim for ostomy supplies, you can file an appeal.

Restrictions On Ostomy Supplies

If a liquid barrier is necessary, you can use either liquid/spray (A4369) or individual wipes/swabs (A5120), but not both.

If you have continent stomas, you can use the following: Stoma cap (A5055), stoma plug (A5081), stoma absorptive cover (A5083) or gauze pads (A6216). However, Medicare doesn’t consider the use of more than one of these types of supplies reasonable and necessary on a given day.

If you have urinary ostomies, you can use either a bag (A4357) or bottle (A5102) for drainage at night, but Medicare won’t cover both.

How to Prevent Medicare Denials of Ostomy Supplies

Have Your Doctor Write a Standard Written Order
 A standard written order contains basic information like your name and your doctor’s name, as well as a description of the items ordered and the quantity to be dispensed. Your health care professional must share the standard written order with the supplier before they submit a claim.
Get Ostomy Supplies Added to Your Medical Record
 Your health care professional should document the medical need for your ostomy supplies around the time he or she writes your first prescription. So long as you continue to need these products and meet eligibility criteria, there’s no need for further documentation unless your needs change in the future.
Make Sure Your Ostomy Supplies are Properly Coded
 Health care professionals must correctly code your items and follow guidelines found in the CMS Healthcare Common Procedure Coding System, or similar publications.
Proof of Delivery
 Medicare requires suppliers to maintain proof of delivery documentation. If a Medicare contractor asks for proof of delivery documentation, your supplier must make it available.

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Christian, Rachel. “Does Medicare Cover Ostomy Supplies?” RetireGuide.com, 20 May 2022, https://www.retireguide.com/medicare/services/durable-medical-equipment/ostomy-supplies/.