Does Medicare Cover Ostomy Supplies?
Ostomy supplies are covered by Medicare so long as your doctor writes a prescription for these items, and you receive them from a medical supplier that accepts Medicare. You will owe 20 percent of the cost for ostomy supplies.
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 large mail-order distributors and local durable medical equipment suppliers.
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 will owe 20 percent of the Medicare-approved amount for these supplies. Medicare pays the other 80 percent.
The Part B deductible — $233 in 2022 — also applies.
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.
|Code||Description||Usual Medicare Maximum Quantities|
|A4357||Bedside drainage bag||2 per month|
|A4362||Solid skin barrier 4x4 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 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 (4x4 inches or smaller)||No maximum listed|
|A4409||Skin barrier with flange, extended wear (4x4 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 (4x4 inches or smaller)||20 per month|
|A4415||Ostomy standard wear skin barrier greater than 4x4 inches||20 per month|
|A4416||Ostomy closed end pouch with filter||60 per month|
|A4417||Ostomy closed end pouch with 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|
In some situations, Medicare may restrict coverage for the type of ostomy supplies you can order.
- 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.
What if Medicare Denies My 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.
Similarly, if you are discharged home with home care, the home health care agency should be provided with this information from your doctor.
Keep in mind that home care agencies reimbursed by Medicare often have ostomy supply costs bundled into the payment for home care.
- 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.
If Medicare denies your claim for ostomy supplies, you can file an appeal.
It may be helpful to review the denial with a health care professional who’s familiar with ostomies prior to filing an appeal. He or she might be able to identify the problem and provide a solution.
You can also call Medicare at 1-800-633-4227 for more information about why your claim was denied, and if needed, assistance with filing an appeal.
6 Cited Research Articles
- Mueller, S. (2021, March). Ostomy Supplies: How You Can Help Your Patients Solve the Puzzle. Retrieved from https://www.o-wm.com/article/ostomy-supplies-how-you-can-help-your-patients-solve-puzzle
- Centers for Medicare & Medicaid Services. (2020, August). Provider Compliance Tips for Ostomy Supplies. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProviderComplianceTipsforOstomySupplies-ICN909480.pdf
- Centers for Medicare & Medicaid Services. (n.d.). Local Coverage Determination (LCD): Ostomy Supplies (L33828). Retrieved from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33828&ContrId=389
- Centers for Medicare & Medicaid Services. (n.d.). Medicare Coverage of Durable Medical Equipment & Other Devices. Retrieved from https://www.medicare.gov/Pubs/pdf/11045-Medicare-Coverage-of-DME.PDF
- Coloplast. (n.d.). General Medicare guidelines for ostomy care. Retrieved from https://www.coloplast.us/Global/US/Ostomy/Professional/Wellness%20Articles/Reimbursement.pdf
- Medicare.gov. (n.d.). Ostomy supplies. Retrieved from https://www.medicare.gov/coverage/ostomy-supplies