| Accessory |
Description |
Usual Maximum Replacement per month |
| A4357 |
Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each |
2 every month |
| A4362 |
Skin barrier; solid, 4 x 4 or equivalent; each |
20 every month |
| A4364 |
Adhesive, liquid or equal, any type, per oz. |
4 every month |
| A4367 |
Ostomy belt, each |
1 every month |
| A4369 |
Ostomy skin barrier, liquid (spray, brush, etc.), per oz. |
2 every month |
| A4377 |
Ostomy pouch, drainable, for use on faceplate, plastic, each |
10 every month |
| A4381 |
Ostomy pouch, urinary, for use on faceplate, plastic, each |
10 every month |
| A4436 |
Irrigation supply; sleeve, reusable, each |
4 every month |
| A4437 |
Irrigation supply; sleeve disposable |
4 every month |
| A4402 |
Lubricant, per ounce |
4 every month |
| A4404 |
Ostomy ring, each |
10 every month |
| A4405 |
Ostomy skin barrier, non-pectin based, paste, per ounce |
4 every month |
| A4406 |
Ostomy skin barrier, pectin-based, paste, per ounce |
4 every month |
| A4414 |
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each |
20 every month |
| A4415 |
Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 44 inches, each |
20 every month |
| A4416 |
Ostomy pouch, closed, with barrier attached, with filter (1 piece), each |
60 every month |
| A4417 |
Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each |
60 every month |
| A4418 |
Ostomy pouch, closed; without barrier attached, with filter (1 piece), each |
60 every month |
| A4419 |
Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each |
60 every month |
| A4420 |
Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each |
60 every month |
| A4423 |
Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each |
60 every month |
| A4424 |
Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each |
20 every month |
| A4425 |
Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each |
20 every month |
| A4426 |
Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each |
20 every month |
| A4427 |
Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each |
20 every month |
| A4429 |
Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each |
20 every month |
| A4431 |
Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each |
20 every month |
| A4432 |
Ostomy pouch, urinary; for use on barrier with nonlocking flange, with faucet-type tap with valve (2 piece), each |
20 every month |
| A4433 |
Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each |
20 every month |
| A4434 |
Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each |
20 every month |
| A4450 |
Tape, non-waterproof, per 18 square inches |
40 every month |
| A4452 |
Tape, waterproof, per 18 square inches |
40 every month |
| A4456 |
Skin barrier, wipes or swabs, each |
50 every month |
| A4481 |
Tracheostoma filter, any type, any size, each |
62 every month |
| A4623 |
Tracheostomy, inner cannula |
62 every month |
| A4625 |
Tracheostomy care kit for new tracheostomy |
31 every month |
| A4626 |
Tracheostomy cleaning brush, each |
2 every month |
| A4629 |
Tracheostomy care kit for established tracheostomy |
31 every month |
| A5051 |
Ostomy pouch, closed; with barrier attached (1 piece), each |
60 every month |
| A5052 |
Ostomy pouch, closed; without barrier attached (1 piece), each |
60 every month |
| A5053 |
Ostomy pouch, closed; for use on faceplate, each |
60 every month |
| A5054 |
Ostomy pouch, closed; for use on barrier with flange (2 piece), each |
60 every month |
| A5055 |
Stoma cap |
31 every month |
| A5056 |
Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each |
40 every month |
| A5057 |
Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each |
40 every month |
| A5061 |
Ostomy pouch, drainable; with barrier attached, (1 piece), each |
20 every month |
| A5062 |
Ostomy pouch, drainable; without barrier attached (1 piece), each |
20 every month |
| A5063 |
Ostomy pouch, drainable; for use on barrier with flange (2-piece system), each |
20 every month |
| A5071 |
Ostomy pouch, urinary; with barrier attached (1 piece), each |
20 every month |
| A5072 |
Ostomy pouch, urinary; without barrier attached (1 piece), each |
20 every month |
| A5073 |
Ostomy pouch, urinary; for use on barrier with flange (2 piece), each |
20 every month |
| A5081 |
Stoma plug or seal, any type |
31 every month |
| A5082 |
Continent device; catheter for continent stoma |
1 every month |
| A5083 |
Continent device, stoma absorptive cover for continent stoma |
150 every month |
| A5093 |
Ostomy accessory; convex insert |
10 every month |
| A5121 |
Skin barrier; solid, 6 x 6 or equivalent, each |
20 every month |
| A5122 |
Skin barrier; solid, 8 x 8 or equivalent, each |
20 every month |
| A5126 |
Adhesive or nonadhesive; disk or foam pad |
20 every month |
| A5131 |
Appliance cleaner, incontinence and ostomy appliances, per 16 oz |
1 every month |
| A6216 |
Gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without adhesive border, each dressing |
60 every month |
| A7501 |
Tracheostoma valve, including diaphragm, each |
1 every month |
| A7502 |
Replacement diaphragm/faceplate for tracheostoma valve, each |
1 every month |
| A7504 |
Filter for use in a tracheostoma heat and moisture exchange system, each |
62 every month |
| A7506 |
Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each |
62 every month |
| A7507 |
Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each |
62 every month |
| A7508 |
Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each |
62 every month |
| A7509 |
Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each |
62 every month |
| A7526 |
Tracheostomy tube collar/holder, each |
31 every month |
| A7505 |
Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each |
2 every month |
| A7520 |
Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each |
1 every month |
| A7521 |
Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each |
1 every month |
| A7524 |
Tracheostoma stent/stud/button, each |
1 every month |
| A7527 |
Tracheostomy/laryngectomy tube plug/stop, each |
2 every month |
| A4361 |
Ostomy faceplate, each |
3 per 6 months |
| A4371 |
Ostomy skin barrier, powder, per oz |
10 per 6 months |
| A4398 |
Ostomy irrigation supply; bag, each |
2 per 6 months |
| A4399 |
Ostomy irrigation supply; cone/catheter, with or without brush |
2 per 6 months |
| A4455 |
Adhesive remover or solvent (for tape, cement or other adhesive), per oz |
16 per 6 months |
| A5102 |
Bedside drainage bottle with or without tubing, rigid or expandable, each |
2 per 6 months |
| A5120 |
Skin barrier, wipes or swabs, each |
150 per 6 months |
| A7503 |
Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each |
1 per 6 months |
| A7522 |
Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each |
1 per year |
