Durable Medical Equipment (DME) supplies — coverage, prior authorization, frequency and quantity limits
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This document lists coverage, prior authorization requirements, frequency and quantity limits for numerous DME supplies (HCPCS A‑codes and common diabetes/infusion supplies) for members of Neighborhood Health Plan of Rhode Island.
No material clinical or coverage changes in this revision.
Item-level Coverage, Prior Authorization, Frequency & Quantity
inv-01: Sample per-item coverage nodes
Per-item coverage, prior authorization, frequency and quantity (examples).
ALL of the following
- A4206: Syringe with needle, sterile 2 cc — Covered for MED/SUB/CSN/RHE/RHP; Commercial = N; Prior Authorization Required for MED/SUB/CSN/RHE/RHP/Commercial = Covered; Integrity Duals/Dual Connect = Covered; Frequency = N/A; Quantity = N/A
inv-02: Per-item coverage nodes
Item-level coverage and limits (selected entries).
ALL of the following
- Disposable endoscope sheath — Covered; Prior Authorization = N; Frequency = N/A; Quantity = N/A
- Integrated lancing and blood sample testing cartridges for home blood glucose monitor — Covered; Prior Authorization = N; Frequency = N/A; Quantity = N/A
- Adhesive skin support attachment for external breast prosthesis — Covered; Prior Authorization = N; Frequency = M; Quantity = 5
- A4281 — Covered (Commercial = N); Prior Authorization = N; Frequency = M; Quantity = 1
- Disposable collection and storage bag for breast milk — Covered; Prior Authorization = N; Frequency = M; Quantity = 300
- A4295 (intermittent catheter, coude) — Covered; Prior Authorization = N; Frequency = M; Quantity = 150
- Insertion trays and indwelling catheter sets (A4311–A4316) — Covered; Prior Authorization = N; Frequency = M; Quantity = 1
- A4320 irrigation tray — Covered; Prior Authorization = N; Frequency = M; Quantity = 4
- Male external catheter with integral collection chamber — Covered; Prior Authorization = N; Frequency = M; Quantity = 4
- Female external urinary pouch — Covered; Prior Authorization = N; Frequency = M; Quantity = 31
- Lubricant, individual sterile packet — Covered; Prior Authorization = Covered for MED lines or Mixed; Frequency = 200; Quantity = 200
- Urinary catheter anchoring device, adhesive — Covered; Prior Authorization = Covered for some lines; Frequency = M; Quantity = 36
- Incontinence supply, miscellaneous — Covered; Prior Authorization = Covered; Frequency = M; Quantity = 30
- Indwelling catheters (foley types, specialty) — Covered; Prior Authorization = N for many entries; Frequency = M; Quantity = 2
- A4341 and accessories — Covered (Commercial = N); Prior Authorization varies; Frequency = M; Quantity varies
inv-03: Item-level coverage criteria (excerpts)
Item-level coverage summary and limits (excerpts).
ALL of the following
- A4341 — Covered for most lines; Commercial = N; Prior Authorization field varies; Frequency = M; Quantity = 1
- Accessories for intraurethral drainage device w/ valve (replacement) — Covered; Prior Authorization = N; Frequency = 5-year; Quantity = 1
- Indwelling catheter, foley two‑way all silicone — Covered; Prior Authorization = N; Frequency = M; Quantity = 2
- Indwelling catheter, foley three‑way — Covered; Prior Authorization = N; Frequency = M; Quantity = 2
- Male external catheter, disposable — Covered; Prior Authorization = N; Frequency = M; Quantity = 35
- A4351 (intermittent straight tip) — Covered; Prior Authorization = N; Frequency = M; Quantity = 200
- Irrigation tubing set for continuous bladder irrigation — Covered; Prior Authorization = N; Frequency = M; Quantity = 31
- A4356 — Covered; Prior Authorization = N; Frequency = Q; Quantity = 1
- Urinary drainage bag, leg or abdomen — Covered; Prior Authorization field blank in places; Frequency = M; Quantity = 4
- Ostomy faceplates and accessories — Covered; Prior Authorization = N for many; Frequency = M–B depending on item; Quantity varies
- A4368 — Covered; Commercial = N; Prior Authorization = Covered for some lines; Frequency = M; Quantity = 60
- A4380 — Covered; Commercial = N; Prior Authorization = Covered for some lines; Frequency = Y; Quantity = 6
- Various ostomy skin barriers/pouches (A4372–A4379 etc.) — Covered; Prior Authorization and frequency vary; Quantity varies (1–20+)
inv-04: Ostomy supply coverage items
Ostomy line-items with coverage, prior authorization, frequency and quantity as listed.
ALL of the following
- Ostomy pouch, urinary, heavy plastic (faceplate) — Covered; Prior Authorization = N; Frequency = M; Quantity = 10
- Ostomy pouch, urinary, rubber (faceplate) — Covered; Prior Authorization = N; Frequency = M; Quantity = 10
- Ostomy faceplate equivalent (silicone ring) — Covered; Prior Authorization = N; Frequency = M; Quantity = 10
- Ostomy skin barrier, solid 4x4 extended wear without convexity — Covered; Prior Authorization = N; Frequency = M; Quantity = 20
- A4388 — Covered; Prior Authorization = N; Frequency = M/B varies; Quantity = 20
- A4389 — Covered; Prior Authorization = N; Quantity = 30
- Ostomy pouch, drainable with extended wear barrier and built-in convexity (1 piece) — Covered (Medicaid/etc.); Commercial = N; Prior Authorization = Covered for some lines; Frequency = M; Quantity = 30
- Ostomy pouch, urinary with extended wear barrier attached (1 piece) — Covered; Commercial = N; Prior Authorization = Covered in some entries; Frequency = M; Quantity = 10
- Ostomy deodorant (liquid) per oz — Covered; Commercial = N; Prior Authorization = Covered; Frequency = M; Quantity = 16
- A4402 lubricant per ounce — Covered; Prior Authorization = N; Frequency = M; Quantity = 8
- A4413 ostomy pouch, drainable high output with filter — Covered; Prior Authorization = N; Frequency = M; Quantity = 20
inv-05: Ostomy supply coverage items and limits
Coverage, prior authorization, frequency and quantity for specific ostomy supply items.
ALL of the following
- Ostomy skin barrier >4x4 with flange without convexity — Covered for MED/SUB/CSN/RHE/RHP and Integrity Duals/Dual Connect; Commercial = N; Prior Authorization Required in many MED/SUB/CSN/RHE/RHP/Commercial entries; Frequency = M; Quantity = 20
- Ostomy pouch, closed, with barrier attached, with filter (1 piece) — Covered; Commercial = N; Prior Authorization varies; Frequency = M; Quantity = 60
- Ostomy pouch, closed with built‑in convexity with filter — Covered; Commercial = N; Prior Authorization = Covered for some Commercial lines; Frequency = M; Quantity = 60
- Ostomy supply; miscellaneous — Covered across lines; Prior Authorization = Y for MED/SUB/CSN/RHE/RHP/Commercial and Integrity/Dual Connect in entries; Frequency = M; Quantity = 30
- Ostomy absorbent material (sheet/pad/crystal) to thicken output — Covered; Commercial = N; Prior Authorization = Covered for MED/etc.; Integrity Duals = Covered; Dual Connect = N; Frequency = 90; Quantity = 90
- Ostomy pouch, drainable with barrier attached with filter (1 piece) — Covered for MED/SUB/CSN/RHE/RHP and Integrity Duals; Commercial = N; Prior Authorization = Covered for many lines; Frequency = M; Quantity = 20
- A4435 ostomy pouch, drainable, high output — Covered across lines; Prior Authorization = N; Frequency = M; Quantity = 20
- Tapes (non-waterproof & waterproof) — Covered; Prior Authorization = N; Frequency = M; Quantity = 40
- Adhesive remover/solvent (per oz) — Covered; Prior Authorization = N; Frequency = B; Quantity = 16; A4456 wipes — Covered; Prior Authorization = N; Frequency = M; Quantity = 50
- A4457 enema tube replacement — Covered for many lines; Prior Authorization = Y for some lines; Dual Connect = Noncovered in entries; Frequency/Quantity = N/A
inv-06: Per-item coverage examples
Per-item coverage rules (examples) showing benefit-line variations, PA flags, and supply limits.
ALL of the following
- Tape, waterproof — Covered for MED/SUB/CSN/RHE/RHP/Commercial; Prior Authorization = N; Frequency = M; Quantity = 40
- Adhesive remover, per ounce — Covered; Prior Authorization = N; Frequency = B; Quantity = 16
- A4456 — Covered; Prior Authorization = N; Frequency = M; Quantity = 50
- A4457 — Covered for MED/SUB/CSN/RHE/RHP/Commercial; Dual Connect = Noncovered; Prior Authorization = Y for several lines; Frequency/Quantity = N/A
- A4481 — Covered; Prior Authorization = N; Frequency = M; Quantity = 62
- A4483 — Covered; Prior Authorization = N; Frequency = M; Quantity = 30
- A4542 — Covered; Prior Authorization = Y; Frequency = M; Quantity = 1
- A4624 — Covered; Prior Authorization = N; Frequency = M; Quantity = 90
inv-07: Per-item coverage rules (excerpt)
Item-level coverage with plan-specific variations and supply limits (tracheostomy & related items, ostomy accessory examples).
ALL of the following
- A4624 (tracheal suction catheter) — Covered; Prior Authorization = N; Frequency = M; Quantity = 90
- A4625 (tracheostomy care kit for new tracheostomy) — Covered; Prior Authorization = N; Frequency = Y; Quantity = 14
- Tracheostomy cleaning brush — Covered; Commercial = N; Prior Authorization varies (some lines = Y); Frequency = 2; Quantity = 2
- Spacer (MDI reservoir) — Covered for MED/SUB/CSN/RHE/RHP; Commercial = N; Integrity Duals = Noncovered; Prior Authorization = Covered/M (mixed) entries; Frequency = 1; Quantity = 1
- Oropharyngeal suction catheter — Covered for most plans; Commercial = N; Dual Connect = Noncovered in entries; Frequency = M; Quantity = 12
- Tracheostomy care kit (established) — Covered; Commercial = N; Prior Authorization = Covered in entries; Frequency = M; Quantity = 31
- Gloves (sterile/non-sterile) — Covered; Commercial = N in some entries; Frequency = M; Quantities as specified per type
inv-08: Composite dressing coverage examples
Composite and foam dressing codes commonly marked Covered with monthly limits.
ALL of the following
- Composite dressing <=16 sq in — Covered; Prior Authorization = N; Frequency = M; Quantity = 12
- Composite dressing >16 <=48 sq in — Covered; Prior Authorization = N; Frequency = M; Quantity = 12
- Composite dressing >48 sq in — Covered; Prior Authorization = N; Frequency = M; Quantity = 12
inv-09: A62xx foam/gauze examples
Selected A62xx foam/gauze dressing examples with stated limits.
ALL of the following
- A6206 (contact layer, sterile, <=16 sq in) — Covered; Prior Authorization = N; Frequency = M; Quantity = 4
- A6210 (foam dressing, >16 <=48 sq in) — Covered; Prior Authorization = N; Frequency = M; Quantity = 12
- A6216 (foam dressing example) — Covered; Prior Authorization = N; Frequency = M; Quantity = 180
inv-10: Hydrogel/hydrocolloid examples
Hydrogel/hydrocolloid dressings listed as covered with monthly quantities.
inv-11: Hydrogel dressing coverage examples
Hydrogel dressing examples and limits.
ALL of the following
- A6241 — Covered; Prior Authorization = N; Frequency = M; Quantity = 12
inv-12: Specialty absorptive dressing coverage examples
Specialty absorptive dressing examples with monthly quantities.
ALL of the following
- A6252 — Covered; Prior Authorization = N; Frequency = M; Quantity = 31
inv-13: Wound cleansers and fillers
Wound cleansers and wound fillers with coverage and PA notes.
ALL of the following
- A6260 (wound cleansers) — Covered; Prior Authorization = Covered for many lines; Frequency = 1; Quantity = 1
- Wound filler (gel/paste) per fl oz — Covered; Prior Authorization = Y for Commercial and other lines; Frequency = M; Quantity = 31
inv-14: Gauze and bandage coverage examples
Gauze and bandage products with frequency and quantity limits.
ALL of the following
- Gauze non-impregnated <=16 sq in — Covered; Prior Authorization = N; Frequency = M; Quantity = 180
- Gauze non-impregnated >48 sq in — Covered; Prior Authorization = N; Frequency = M; Quantity = 93
inv-15: Bandage product coverage examples
Bandages, pads and conforming bandages with stated quantities.
ALL of the following
- A6407 — Covered (MED groups); Commercial = N or blank; Prior Authorization = Covered in some entries; Frequency = M; Quantity = 31
- Conforming bandage (<3 inches) — Covered; Prior Authorization = N; Frequency = M; Quantity = 150
inv-16: Bandages and conforming bandages
Many bandage and conforming bandage items are Covered; PA generally not required.
inv-17: Tubular dressings and compression burn garments
Tubular dressings and custom compression burn garments with quantities and frequencies.
ALL of the following
- Tubular dressing with or without elastic, per linear yard — Covered; Prior Authorization = N; Frequency = M; Quantity = 50
- Compression burn garment, bodysuit (custom) — Covered; Prior Authorization = N; Frequency = Y; Quantity = 8 (4L/4R)
inv-18: Items with commercial prior-authorization differences
Examples of items with commercial prior-authorization differences.
inv-19: Per-item coverage criteria (excerpt)
Per-item coverage, prior authorization, frequency, and quantity rules (A65xx, gradient compression, wound care set).
ALL of the following
- A6511 — Covered; Prior Authorization = N for many lines; Frequency = Y; Quantity = 8 (4L/4R)
- A6512 — Covered; Prior Authorization = Y for multiple benefit types; Frequency = Y; Quantity = 16 (8L/8R)
- A6513 — Covered; Prior Authorization = Y; Frequency = Y; Quantity = 8 (4L/4R)
- A6515–A6519 — Covered; Prior Authorization = Y; Frequency = B or Y depending on item; Quantity = typically 3 or 1
- A6520–A6523 — Covered; Prior Authorization mix of Y/N across benefit types; Frequency = Y; Quantity = 1
- Gradient compression garments (A6530–A6539 etc.) — Mostly Covered for core benefit types; Commercial and Dual coverage varies; Prior Authorization mix of Y/N; Frequency = Y or B; Quantities range 1–16
- Wound care set (NPWT) — Covered across benefit types; Prior Authorization = N; Frequency = M; Quantity = 15
- A6552 — Covered; Prior Authorization = N for main benefits, Y for some Dual plans; Frequency = B; Quantity = 3
inv-20: Item-level coverage rules
Item-level coverage rules for wound care sets and gradient compression items.
ALL of the following
- Wound care set (negative pressure wound therapy) — Covered; Prior Authorization = N for listed plans; Quantity = 15; Frequency = Monthly; Includes all supplies and accessories
- A6552 — Covered for MED/SUB/CSN/RHE/RHP and Commercial; Prior Authorization = N for core benefits, Y for some Dual plans; Quantity = 3; Frequency = Bi-annual
- Gradient compression stockings (below knee 40+ mm Hg) — Covered; Prior Authorization varies (N for main plans, Y for Integrity/Dual Connect in some entries); Quantity = 3; Frequency = Bi-annual
- Gradient compression garments/wraps — Covered for Medicaid lines; Commercial often N; Prior Authorization varies; Quantity = 3; Frequency commonly Bi-annual or indicated multi-year
inv-21: Per-item coverage and limits
Per-item coverage entries indicating payer-line coverage, prior authorization, frequency and quantity for gradient compression and suction supplies.
ALL of the following
- Gradient compression wrap with adjustable straps (NOS) — Covered; Commercial = N; Prior Authorization entries present; Frequency mapping indicates multi‑year mapping to quantity = 3
- Gradient pressure wraps (above knee/full leg/foot/arm/bra) — Generally Covered; Commercial often = N; Prior Authorization entries vary; Frequency often 2-5 years or Bi-annual; Quantity frequently = 3
- External urinary catheters (disposable) for suction pump — Covered; Commercial = N; Prior Authorization entries present; Frequency = M; Quantity = 1 (30 catheters per month)
- Canister, disposable (suction pump) — Covered; Commercial = N; Frequency = M; Quantity = 10
- Canister, non-disposable (suction pump) — Covered; Commercial = N; Quantity = 1
- Tubing used with suction pump — Covered; Commercial = N; Frequency = Q; Quantity = 3
- Gradient compression bandaging supplies (liners/liners/rolls) — Covered; Commercial often = Y; Prior Authorization varies; Frequency/Quantity as listed per item
inv-22: Itemized coverage and limits
Itemized coverage and limits: product lists include payer-line coverage, prior authorization flags, frequency codes, and quantity limits (segment index).
HCPCS A‑Code Listings & Quantity/Frequency Highlights
| A4206 | Syringe with needle, sterile 2 cc |
| A4209 | Syringe with needle, sterile 5 cc or greater |
| A4212 | Non-coring needle or stylet with or without catheter |
| A4213 | Syringe, sterile, 20 cc or greater |
| A4216 | Sterile water, saline and/or dextrose diluent/flush, 10 ml |
| A4232 | Listed A4232 and other A4xxx codes present |
| A4258 | A4258 present |
| A4262 | Temporary, absorbable lacrimal duct |
| A4281 | Adapter/related breast pump item (A4281 listed) |
| A4295 | Intermittent urinary catheter; Coude (curved) tip, hydrophilic coating |
| A4311 | Insertion tray with indwelling catheter, foley type, two-way latex with coating |
| A4320 | Irrigation tray with bulb or piston syringe |
| A4331 | Male/Female external catheter/accessories (male external catheter with integral collection chamber referenced) |
| A4341 | Accessories for patient inserted indwelling intraurethral drainage device with valve |
| A4341 | Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only |
| A4351 | Intermittent urinary catheter; straight tip |
| A4352 | Intermittent urinary catheter; curved tip |
| A4356 | Catheter-related item (A4356 referenced) |
| A4368 | Ostomy skin barrier, liquid (per oz) |
| A4380 | Ostomy pouch, urinary, for use on faceplate, plastic |
| A4388 | Ostomy-related supply (A4388) |
| A4389 | Ostomy-related supply (A4389) |
| A4398 | Ostomy irrigation supply; cone/catheter, with or without brush |
| A4402 | Lubricant, per ounce |
| A4404 | Ostomy ring, each |
| A4405 | Ostomy skin barrier, non-pectin paste, per ounce |
| A4406 | Ostomy skin barrier, pectin-based paste, per ounce |
| A4407 | Ostomy skin barrier with flange, extended wear, with convexity |
| A4412 | Ostomy-related supply (A4412 referenced) |
| A4413 | Ostomy pouch, drainable, high output, with filter |
| A4429 | Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, faucet-type tap (1 piece) |
| A4435 | Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system) |
| A4438 | Ostomy pouch/related HCPCS code (A4438) |
| A4456 | Adhesive remover, wipes, any type, each |
| A4457 | Enema tube, replacement only, each |
| A6241-A6246 | Hydrogel dressings and related items (various sizes, adhesive/no adhesive) |
| A6252-A6255 | Specialty absorptive dressings (various sizes, adhesive/no adhesive) |
| gauze (various entries) | Gauze impregnated and non-impregnated, various sizes and quantity limits |
| Items described by description strings (e.g., gradient compression wrap, bandage liner, canister) with no explicit HCPCS code in this extract |
| A7027 | Combination oral/nasal mask, used with continuous positive airway (A7027) |
| A7028 | Oral cushion for combination oral/nasal mask, replacement only (A7028) |
| A7029 | Nasal pillows for combination oral/nasal mask, replacement only, pair (A7029) |
| A7030 | Full face mask used with positive airway pressure device, each (A7030) |
| A7031 | Face mask interface, replacement for full face mask, each (A7031) |
| A7032 | Cushion for use on nasal mask interface, replacement only, each (A7032) |
| A7033 | Pillow for use on nasal cannula type interface, replacement only, pair (A7033) |
| A7034 | Nasal interface (mask or cannula type) used with positive airway pressure device (A7034) |
| A7035 | Headgear used with positive airway pressure device (A7035) |
| A7036 | Chinstrap used with positive airway pressure device (A7036) |
Prior Authorization, Documentation & Payer-Variations — Actionable Notes
Plan-differentiated PA requirements
Prior authorization requirements vary by code and plan. Many HCPCS items are Covered for Medicaid and dual plans but marked Noncovered (N) or Commercial-specific exceptions for Commercial lines. For most listed codes the general PA status is either Not Required (N) or Covered (i.e., PA required and handled as covered) — however several items and product groups include plan-differentiated PA flags (Commercial = N vs Medicaid/Dual = Covered) or mixed values (Covered, Y, M, blank). Providers should verify plan line and code-level PA before ordering.
- Plan-differentiated PA requirements observed across many items — Commercial lines frequently show Noncovered (N) while MED/SUB/CSN/RHE/RHP and Integrity Duals/Dual Connect often show Covered.
- Prior authorization general status: many HCPCS entries list PA Required = N (no PA) for most benefit lines; some list PA Required = Covered (PA required and covered).
- Item-level prior authorization exceptions: specific codes (examples below) show mixed PA flags across plan lines — treat each code individually.
A4341 coverage & prior auth notes
A4341 is listed Covered for MED/SUB/CSN/RHE/RHP and Integrity Duals/Dual Connect, but Commercial shows Noncovered. Prior Authorization is not required for Integrity Duals and Dual Connect (PA = N). Frequency is typically monthly with Quantity = 1. Providers should note the Commercial exclusion and that dual plans do not require PA.
A4352/A4353 coverage & prior auth
A4352 and A4353 are Covered for Medicaid and dual lines but marked Noncovered for Commercial. PA flags vary: A4353 explicitly lists PA Required = N for base benefit lines, while PA for dual lines = N. Frequency and quantity limits apply (monthly, Quantity = 200). Confirm Commercial eligibility before supply requests.
Multiple HCPCS coverage & prior auth summary
Multiple HCPCS codes show mixed coverage and PA statuses — examples include A4218, A4380, A4429, A4368, and many ostomy-related codes. Common patterns: MED/SUB/CSN/RHE/RHP typically Covered; Commercial often N or Covered depending on code; Integrity Duals/Dual Connect can be Covered with PA = N or set to M (monthly review). Providers must check the specific HCPCS entry for coverage, PA, frequency, and quantity prior to ordering.
Plan-specific coverage/authorization variations
Plan-specific coverage/authorization variations are frequent. Many items show Commercial = N while Medicaid and dual lines are Covered. Dual plans (Integrity Duals, Dual Connect) sometimes have PA = N even when base lines list PA = Covered. Some dual entries use M (monthly) or Y (annual/other) in PA or frequency fields. Confirm member plan line before submitting claims.
- Commercial lines may be Noncovered for items otherwise Covered for Medicaid and dual plans.
- Dual plans (Integrity Duals, Dual Connect) may have different PA flags (N, M, or blank).
- Frequency codes legend: M = Monthly, Q = Quarterly, B = Bi-annual, Y = Annual, 2-5 = Years — used with PA/limits.
Prior authorization requirements for ostomy skin barriers
Ostomy skin barriers (liquid, powder, barriers with flange, extended wear barriers) show mixed PA requirements. Many ostomy skin barrier items are Covered for Medicaid and dual plans; Commercial entries vary. PA is often Not Required (N) for base lines but some ostomy pouch items and extended wear barriers list PA = Covered or PA = M for dual plans. Providers should confirm code-specific PA and quantity/frequency rules before dispensing.
- Ostomy skin barrier, liquid/powder: MED/SUB/CSN/RHE/RHP = Covered; Commercial may be Covered or N; PA often = N.
- Ostomy skin barrier with flange (larger than 4x4): PA Required = Covered for base lines; Dual Connect/Integrity Duals PA = N.
- Extended wear ostomy pouches: some items show Commercial = N with PA = Covered on base lines; dual PA may be M (monthly) or N.
Prior authorization for miscellaneous ostomy supplies
Miscellaneous ostomy supplies (A4368, 'Ostomy supply; miscellaneous') frequently require prior authorization. The policy shows PA = Y for the miscellaneous category across many lines, including Integrity Duals and Dual Connect for some entries. Quantity limits and monthly frequency typically apply. Obtain PA prior to billing when the item is listed as miscellaneous.
- Ostomy supply; miscellaneous: MED/SUB/CSN/RHE/RHP = Covered; Commercial = Covered but PA = Y.
- Integrity Duals/Dual Connect: miscell. supplies often require PA = Y.
- Frequency = M; Quantity examples = 30 for miscellaneous supplies.
Authorization notes for A4429
A4429 and related ostomy pouch codes show that Commercial is often Noncovered while Medicaid and dual plans are Covered. PA Required for many A4429 entries is listed as Covered (i.e., PA must be obtained) for base benefit lines; dual plan PA flags are usually N. Providers should secure prior authorization for A4429 when servicing non-dual Medicaid lines.
Mixed prior authorization and coverage exceptions
There are mixed prior authorization and coverage exceptions across the policy: some codes are Noncovered for Commercial but Covered with PA for Medicaid; others are Covered with PA = N. Examples include wound care items (A6260), spacers/reservoirs for MDIs, and certain A65xx compression devices which frequently carry PA = Y for Commercial or custom items. Always check the specific code and plan line.
- Wound care A6260: Commercial = N; PA = Covered for base lines; dual PA = M.
- Spacer (MDI reservoir): MED lines Covered, Commercial = N, PA = Covered; Integrity Duals = Noncovered.
- A65xx items (custom compression, gradient wraps): many require PA = Y for Commercial/custom lines.
Spacer authorization/coverage nuance
Spacer devices (bag or reservoir for MDI) are Covered for Medicaid lines but Commercial is frequently Noncovered. PA for spacers is often listed as Covered for base lines, Integrity Duals may be Noncovered, and Dual Connect entries vary (PA = M for monthly review). Frequency is commonly 1 per year. Verify member plan and PA before dispensing spacers.
- Spacer, bag or reservoir: MED/SUB/CSN/RHE/RHP = Covered; Commercial = N.
- Prior Authorization Required (MED...Commercial) = Covered; Integrity Duals = Noncovered.
- Dual Connect PA = M in some entries; Frequency = 1; Quantity varies.
Code-specific prior auth notes
Code-specific prior authorization notes: several items explicitly require PA = Y (e.g., A4457 enema tube, A4542/A4543 transcutaneous supplies, various A45xx-A46xx items). Others show PA = N across all benefit lines (e.g., surgical trays A4550, many wound care dressings). Check the code-level entry for PA flags and the member's plan line.
Prior authorization status — general
Overall prior authorization status: while many codes list PA Required = N (no prior auth) across plan types, there are numerous exceptions where PA is required (Covered or Y) or plan-differentiated. Providers should not assume uniform PA rules — validate each HCPCS with the member's plan line.
- Many HCPCS entries: PA Required = N for MED/SUB/CSN/RHE/RHP and sometimes for Commercial.
- Exceptions exist where PA Required = Covered or Y; dual plans may have separate PA flags.
Exceptions with prior authorization required
Exceptions with prior authorization required: specific wound care (A6260), custom compression (A6512, A6513) and gradient/compression wraps (A6515-A6517, A6552-A6553) frequently carry PA = Y for Commercial/custom entries and sometimes for dual plans. Anticipate PA for custom or higher-cost items.
Prior authorization status (examples)
Numerous example entries illustrate PA status variability: wound care set for NPWT is Covered with PA = N and monthly frequency (Quantity = 15). CPAP interfaces (A7027-A7029) generally list PA = N across benefit lines. Gradient compression wraps and interfaces for respiratory devices show mixed PA flags depending on customness and commercial coverage.
- Wound care set (NPWT): Covered; Prior Authorization Required = N; Frequency = M; Quantity = 15.
- CPAP interfaces (A7027-A7029): Covered across plans listed; Prior Authorization Required = N.
- Gradient compression and other custom devices: PA and coverage vary by Commercial vs Medicaid/dual lines.
Prior authorization exceptions (examples)
Prior authorization exceptions (examples): some A65xx codes (A6552, A6553) show PA flags that differ between Commercial and Integrity Duals/Dual Connect; one entry shows A6552 PA = N for base lines but PA = Y for Integrity Duals/Dual Connect. Verify these code-level exceptions when dispensing.
Item-level prior authorization summary
Item-level summary: many HCPCS items list PA Required = N across benefit types, but significant numbers list PA = Covered, Y, M or blank — particularly for ostomy supplies, custom compression, and certain respiratory/nebulizer interfaces. Check frequency and quantity limits (monthly/quarterly/biannual) as these often accompany PA requirements.
- Common PA markers: N (no PA), Covered (PA required and covered), Y (prior auth required), M (monthly review) — present across ostomy, wound care, respiratory categories.
- Frequency/Quantity often specified alongside PA (e.g., M, Q, B, Y, 2-5).
Wound care set (NPWT) authorization note
Wound care set for negative pressure wound therapy (NPWT) is Covered across benefit lines and does not require prior authorization (PA = N). Frequency is monthly and Quantity limit is 15 per month. Providers supplying NPWT wound care sets do not need PA but must adhere to frequency/quantity limits.
- Wound care set (NPWT): MED/SUB/CSN/RHE/RHP/Commercial = Covered.
- Prior Authorization Required = N for listed lines.
- Frequency = M; Quantity = 15.
Gradient pressure wraps — commercial coverage and prior auth
Gradient pressure/wraps: many entries show Commercial = N while MED/SUB/CSN/RHE/RHP = Covered. Prior authorization for gradient compression and pressure wraps is commonly required (PA = Covered or Y) for Commercial or custom items; dual plans may show PA = B (bi-annual) or Y. Quantity and frequency (usually 3 per period or per 2-5 years) vary by code. Confirm plan line and whether item is custom.
- Gradient compression wrap/wraps: MED lines Covered; Commercial often N or Covered depending on customness.
- PA often required for Commercial/custom items (PA = Covered or Y); Dual plan PA may be B or Y.
- Frequency examples: 3 per period, Quantity = 3; some custom items use bi-annual/years fields.
CPAP interface prior auth
CPAP interfaces (A7027, A7028, A7029 and related mask components) are generally Covered and list Prior Authorization Required = N across MED/SUB/Commercial and dual plans shown. Frequency and quantity limits apply (e.g., A7027 Q=1 quarterly, A7028 Quantity=6 annually). Providers can generally supply these without prior authorization but must follow quantity/frequency limits.
Commercial line variability
Commercial line variability: Commercial benefit lines frequently diverge from Medicaid and dual plans — items marked Covered for Medicaid/dual may be Noncovered for Commercial. Commercial entries also more often require prior authorization (PA = Y or Covered) for custom, high-cost, or miscellaneous supplies. Always verify Commercial benefits and PA requirements before procurement.
- Commercial = N appears across many codes where Medicaid/dual = Covered.
- Commercial/custom items frequently have PA = Y or Covered.
- Providers must validate Commercial member eligibility, coverage, and PA prior to ordering.
Definitions, Frequency Codes & Product Terms
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