ModifiedNew York State Department of HealthPolicy N/A

Update Regarding Incontinence Products (Diapers/Liners/Underpads) Quantity Allowance, Coverage Criteria/Guidelines, and System Edits

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NYS Medicaid coverage criteria, quantity allowances, documentation, prior approval, and claims edits for disposable and reusable diapers, liners, and underpads.

Policy Summary

PayerNew York State Department of Health

PolicyIncontinence Products: Quantity Allowance, Coverage Criteria/Guidelines, and System Edits

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2026 (FFS); October 1, 2026 (MLTC)

Next Review DateNot specified

Key ActionApply the revised criteria to new prior authorizations and prior approval requests initiated on or after the applicable effective date.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria and general guidelines for incontinence products were revised.

The allowance for disposable underpads billed under A4554 is reduced from 300 to 150 per applicable period.

Reusable and disposable products of the same type may not be obtained within the same 30-day period.

Maximum 30-day quantities are established for disposable and reusable diapers, liners, and underpads.

Adult and youth sized products must meet specified NYS DOH product performance and construction standards supported by independent laboratory documentation.

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ModifiedNew York State Department of HealthPolicy N/A

Update Regarding Incontinence Products (Diapers/Liners/Underpads) Quantity Allowance, Coverage Criteria/Guidelines, and System Edits

Customize your policy alerts

Sign up for all New York State Department of Health policy alerts

Know when New York State Department of Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

NYS Medicaid coverage criteria, quantity allowances, documentation, prior approval, and claims edits for disposable and reusable diapers, liners, and underpads.

Policy Summary

PayerNew York State Department of Health

PolicyIncontinence Products: Quantity Allowance, Coverage Criteria/Guidelines, and System Edits

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2026 (FFS); October 1, 2026 (MLTC)

Next Review DateNot specified

Key ActionApply the revised criteria to new prior authorizations and prior approval requests initiated on or after the applicable effective date.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria and general guidelines for incontinence products were revised.

The allowance for disposable underpads billed under A4554 is reduced from 300 to 150 per applicable period.

Reusable and disposable products of the same type may not be obtained within the same 30-day period.

Maximum 30-day quantities are established for disposable and reusable diapers, liners, and underpads.

Adult and youth sized products must meet specified NYS DOH product performance and construction standards supported by independent laboratory documentation.

250Maximum disposable diapers/liners per 30 days

150Maximum disposable underpads per 30 days

5Maximum reusable diapers per 30 days

4Maximum reusable underpads per 30 days

8/dayMaximum supported changes per day

<2.0 gRequired maximum rewet rate

Coverage Criteria

Clinical coverage requirements

Covered when all applicable requirements are met.

All coverage requirements

The member has urinary and/or fecal incontinence, and the ordering practitioner documents the medical need and the condition causing the incontinence in the member’s medical record.
The ordering practitioner documents medical necessity for the overall quantity of supplies needed to meet the member’s bladder and bowel management needs.
The requested product type and one-month quantity are appropriate for and justified by the member’s documented medical needs and the ordering practitioner’s frequency or quantity order.

Minimum product specifications

Adult and youth sized products must meet all applicable product standards.

Product specifications: The product has no plastic or non-breathable backing; a rewet rate of less than 2.0 g; a rate of acquisition below 60 seconds; retention capacity above 250 g; breathable zones with a minimum value above 100 cubic feet per minute (cfm); and, when the product has closures, a closure system that permits multiple fastening and unfastening occurrences.Rewet rate <2.0 g; rate of acquisition <60 seconds; retention capacity >250 g; breathable zones >100 cfm

Compliance must be verified through independent laboratory testing documentation maintained by the DMEPOS provider and made available to the Department upon request.

Quantity limits

Standard 30-day quantity limits apply.

Diapers and liners quantity options

No more than 250 disposable diapers and/or liners are provided within 30 days.Up to 250 per 30 days
This allowance supports up to eight changes per day.
No more than five reusable diapers are provided within 30 days.Maximum 5 per 30 days
Reusable and disposable diapers may not be combined within the same 30-day period.

Underpad quantity options

No more than 150 disposable underpads are provided within 30 days.Up to 150 per 30 days

Diapers, liners, and underpads are not covered for children age three or younger when the lack of bladder or bowel control is attributable to normal developmental processes.

Personal hygiene products are not covered, including menstrual pads. Disposable incontinence liners are distinct from menstrual pads and are not classified as personal hygiene products when used for incontinence.

Reusable and disposable products of the same type may not be obtained within the same 30-day period. This restriction applies to diapers and to underpads; claims combining reusable and disposable items of the same type during that period will be denied.

The requested product type and quantity must be supported by the member’s medical records, the ordering practitioner’s order, and the medical condition causing the incontinence. One-month quantities must reflect the practitioner’s ordered frequency or quantity and be appropriate and justified by the member’s medical needs.

Codes and Product Standards

Updated QuantityHCPCSCovered

A4554

# Disposable underpads, all sizes, (e.g., Chux's), each; old quantity 300; new quantity 150

Incontinence Product Codes Affected by Revised Criteria and GuidelinesHCPCSCovered

A4554	# Disposable underpads, all sizes, (e.g., Chux's), each
T4521	# Adult sized disposable incontinence product, brief/diaper, small, each
T4522	# Adult sized disposable incontinence product, brief/diaper, medium, each
T4523	# Adult sized disposable incontinence product, brief/diaper, large, each
T4524	# Adult sized disposable incontinence product, brief/diaper, extra-large, each
T4529	# Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each
T4530	Small/medium size, each # Pediatric sized disposable incontinence product, brief/diaper, large size, each
T4533	# Youth sized disposable incontinence product, brief/diaper, each
T4535	# Disposable liner/shield/guard/pad/undergarment, for incontinence, each
T4537	# Incontinence product, protective underpad, reusable, bed size, each

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Rewet rate

Applicable productsAdult and youth sized incontinence products

Required rewet rate<2.0 g

VerificationIndependent laboratory testing documentation must verify compliance and be maintained by the DMEPOS provider

Rate of Acquisition (ROA)

Applicable productsAdult and youth sized incontinence products

Required Rate of Acquisition (ROA)<60 seconds

Verification

Provider and Billing Requirements

Note

Implementation for New Requests

Apply the revised criteria and general guidelines to new prior authorizations and prior approval requests for incontinence products initiated on or after the applicable implementation date.

NYS Medicaid Fee-for-Service (FFS): requests initiated on or after July 1, 2026.
Managed Long Term Care (MLTC) Plans: requests initiated on or after October 1, 2026.
The previously published ordering tool has been removed and quantities have been simplified. Continue submitting appropriate diagnosis codes for payment.

Prior Authorization

Prior Approval for Excess Quantities

Requests for quantities above the applicable 30-day limits may be reviewed case by case through prior approval. The request must include supporting clinical documentation of a medical condition resulting in increased urine or stool output.

Submit clinical support for the increased quantity and the underlying medical condition.

Policy Background

This policy governs NYS Medicaid coverage of absorbent products used to manage urinary and/or fecal incontinence, including disposable and reusable diapers, liners, and underpads. Coverage requires documented medical need, an appropriate product type and quantity, and supporting clinical documentation. Standard limits include up to 250 disposable diapers and/or liners per 30 days, up to 150 disposable underpads per 30 days, or the applicable reusable-product limits.

Medical Necessity Requirements

DME medical necessity

DME coverage requires documented incontinence and medically necessary product selection and quantity.

Medical need: Urinary and/or fecal incontinence is documented by the ordering practitioner and maintained in the member’s medical record. The medical record identifies the medical reason and condition causing the incontinence.

Product and quantity justification: The ordering practitioner documents the medical necessity for the requested product type and the overall quantity required for the member’s bladder and bowel management. The requested types and quantities are appropriate to the member’s medical needs and supported by the practitioner’s order.

Required Documentation

Documentation Required

Verify and retain laboratory testing

For adult and youth sized products, verify that independent laboratory documentation establishes compliance with the applicable NYS DOH minimum product specifications. Retain the documentation and provide it to the Department upon request.

No plastic, non-breathable backing
Rewet rate of <2.0 g
Rate of Acquisition of <60 seconds
Retention capacity of >250 g
Breathable zones with a minimum value of >100 cfm
An eligible closure system for products that have closures

Documentation Required

Retain member measurement records

Maintain waist or hip measurements, weight, or comparable measurements supporting the specific product type and size dispensed. These records must support reimbursement.

Noncovered Products and Circumstances

The following are not covered: diapers, liners, and underpads for children age three or younger when the lack of bladder or bowel control is part of normal development; personal hygiene products, including menstrual pads; and reusable and disposable items of the same type obtained within the same 30-day period.

Policy Summary

PayerNew York State Department of Health

PolicyIncontinence Products: Quantity Allowance, Coverage Criteria/Guidelines, and System Edits

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2026 (FFS); October 1, 2026 (MLTC)

Next Review DateNot specified

Key ActionApply the revised criteria to new prior authorizations and prior approval requests initiated on or after the applicable effective date.

SourceLink

On This Page

No more than two reusable bed underpads and two reusable chair underpads are provided within 30 days.Maximum 4 reusable underpads per 30 days

The reusable underpad maximum consists of two bed underpads and two chair underpads. Reusable and disposable underpads may not be combined within the same 30-day period.

Independent laboratory testing documentation must verify compliance and be maintained by the DMEPOS provider

Retention capacity

Applicable productsAdult and youth sized incontinence products

Required retention capacity>250 g

VerificationIndependent laboratory testing documentation must verify compliance and be maintained by the DMEPOS provider

Breathable zones

Applicable productsAdult and youth sized incontinence products

Required breathable-zone value>100 cubic feet per minute (cfm)

VerificationIndependent laboratory testing documentation must verify compliance and be maintained by the DMEPOS provider

Disposable diapers and/or liners

Maximum allowanceUp to 250 disposable diapers and/or liners per 30 days

Supported frequencyUp to eight changes per day

Overage ruleClaims for any combination of diapers and/or liners over 250 per 30 days will be denied

Reusable diapers

Maximum allowanceFive reusable diapers per 30 days

Period30 days

Combination ruleReusable and disposable diapers may not be combined within the same 30-day period

Disposable underpads

Maximum allowanceUp to 150 disposable underpads per 30 days

Period30 days

Combination ruleReusable and disposable underpads may not be combined within the same 30-day period

Reusable underpads

Bed underpadsMaximum two reusable bed underpads every 30 days

Chair underpadsMaximum two reusable chair underpads every 30 days

Total allowanceFour reusable underpads total every 30 days

Approval is not automatic; quantities above the limits remain subject to prior approval review.

Documentation Required

Clinical Medical-Necessity Documentation

Diapers, liners, and underpads are covered for treatment of urinary and/or fecal incontinence when the ordering practitioner documents the medical need and the documentation is maintained in the member’s medical record. The ordering practitioner must also document the medical necessity for the overall quantity needed to meet the member’s bladder and bowel management needs.

Medical records must support the appropriateness of the types and quantities requested, including the medical reason and condition causing the incontinence.
For a one-month supply, the quantity provided must be based on the frequency or quantity ordered by the ordering practitioner and must be appropriate and justified by the member’s medical needs.

Documentation Required

Verify Product Specifications

Before dispensing adult- or youth-sized incontinence products, verify through independent laboratory testing documentation that the products meet the NYS Department of Health minimum specifications. The DMEPOS provider must retain the documentation and make it available to the Department upon request.

No plastic (non-breathable) backing.
Rewet rate <2.0g; Rate of Acquisition (ROA) <60 seconds; retention capacity >250 g.
Breathable zones with a minimum value of >100 cubic feet per minute (cfm).
A closure system allowing multiple fastening and unfastening occurrences, when the product has closures.

Documentation Required

Maintain Size and Measurement Records

Maintain measurement documentation supporting reimbursement for the specific type and size of product dispensed.

Record measurements such as waist/hip size and weight.
Ensure the recorded measurements support both the product type and the size selected.

Documentation Required

Support Product Type and Quantity

Ensure the medical record, fiscal order, and one-month supply documentation support the type and quantity of incontinence products billed. The quantity provided must match the ordering practitioner’s frequency or quantity order and be justified by the member’s medical needs.

Medical records must document the medical reason and condition causing the incontinence and support the requested types and quantities.
The ordering practitioner’s documentation must support medical necessity for the overall quantity needed for bladder and bowel management.
Retain the supporting records for Department review upon request.

Unsupported block type: denial_risk

Denial Risk

Personal Hygiene Products Are Not Covered

Disposable liners intended for incontinence are not menstrual pads. Personal hygiene products, including menstrual pads, are not covered as incontinence supplies.

Do not bill menstrual pads or other personal hygiene products as covered incontinence liners.
Confirm that the product is an incontinence liner and that the member meets the applicable coverage criteria.