Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 19003 | Noridian Healthcare Solutions, LLC | DME MAC | AK AS AZ CA CNMI GU HI IA ID KS MO MT ND NE NV OR SD UT WA WY |
| 18003 | CGS Administrators, LLC | DME MAC | AL AR CO FL GA LA MS NC NM OK PR SC TN TX VA VI WV |
| 17013 | CGS Administrators, LLC | DME MAC | IL IN KY MI MN OH WI |
| 16013 | Noridian Healthcare Solutions, LLC | DME MAC | CT DC DE MA MD ME NH NJ NY PA RI VT |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Article A52487 (Ostomy Supplies - Policy Article) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A52487: Ostomy Supplies - Policy Article (Article, effective 2022-01-01)
- Covered ICD-10-CM codes
- 10
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 0
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| K94.00 | — |
| K94.03 | — |
| K94.10 | — |
| K94.13 | — |
| Z43.2 | — |
| Z43.3 | — |
| Z43.6 | — |
| Z93.2 | — |
| Z93.3 | — |
| Z93.6 | — |
Procedure codes named in the LCD
A4331 (Extension Drainage Tubing, Any Type, Any Length, With Connector/Adaptor, For Use With Urinary Leg Bag Or Urostomy Pouch, Each), A4357 (Bedside Drainage Bag, Day Or Night, With Or Without Anti-Reflux Device, With Or Without Tube, Each), A4361 (Ostomy Faceplate, Each), A4362 (Skin Barrier; Solid, 4 X 4 Or Equivalent; Each), A4363 (Ostomy Clamp, Any Type, Replacement Only, Each), A4364 (Adhesive, Liquid Or Equal, Any Type, Per Oz), A4366 (Ostomy Vent, Any Type, Each), A4367 (Ostomy Belt, Each), A4368 (Ostomy Filter, Any Type, Each), A4369 (Ostomy Skin Barrier, Liquid (Spray, Brush, Etc.), Per Oz), A4371 (Ostomy Skin Barrier, Powder, Per Oz), A4372 (Ostomy Skin Barrier, Solid 4 X 4 Or Equivalent, Standard Wear, With Built-In Convexity, Each), A4373 (Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), With Built-In Convexity, Any Size, Each), A4375 (Ostomy Pouch, Drainable, With Faceplate Attached, Plastic, Each), A4376 (Ostomy Pouch, Drainable, With Faceplate Attached, Rubber, Each), A4377 (Ostomy Pouch, Drainable, For Use On Faceplate, Plastic, Each), A4378 (Ostomy Pouch, Drainable, For Use On Faceplate, Rubber, Each), A4379 (Ostomy Pouch, Urinary, With Faceplate Attached, Plastic, Each), A4380 (Ostomy Pouch, Urinary, With Faceplate Attached, Rubber, Each), A4381 (Ostomy Pouch, Urinary, For Use On Faceplate, Plastic, Each), A4382 (Ostomy Pouch, Urinary, For Use On Faceplate, Heavy Plastic, Each), A4383 (Ostomy Pouch, Urinary, For Use On Faceplate, Rubber, Each), A4384 (Ostomy Faceplate Equivalent, Silicone Ring, Each), A4385 (Ostomy Skin Barrier, Solid 4 X 4 Or Equivalent, Extended Wear, Without Built-In Convexity, Each), A4387 (Ostomy Pouch, Closed, With Barrier Attached, With Built-In Convexity (1 Piece), Each), A4388 (Ostomy Pouch, Drainable, With Extended Wear Barrier Attached, (1 Piece), Each), A4389 (Ostomy Pouch, Drainable, With Barrier Attached, With Built-In Convexity (1 Piece), Each), A4390 (Ostomy Pouch, Drainable, With Extended Wear Barrier Attached, With Built-In Convexity (1 Piece), Each), A4391 (Ostomy Pouch, Urinary, With Extended Wear Barrier Attached (1 Piece), Each), A4392 (Ostomy Pouch, Urinary, With Standard Wear Barrier Attached, With Built-In Convexity (1 Piece), Each), A4393 (Ostomy Pouch, Urinary, With Extended Wear Barrier Attached, With Built-In Convexity (1 Piece), Each), A4394 (Ostomy Deodorant, With Or Without Lubricant, For Use In Ostomy Pouch, Per Fluid Ounce), A4395 (Ostomy Deodorant For Use In Ostomy Pouch, Solid, Per Tablet), A4396 (Ostomy Belt With Peristomal Hernia Support), A4398 (Ostomy Irrigation Supply; Bag, Each), A4399 (Ostomy Irrigation Supply; Cone/Catheter, With Or Without Brush), A4402 (Lubricant, Per Ounce), A4404 (Ostomy Ring, Each), A4405 (Ostomy Skin Barrier, Non-Pectin Based, Paste, Per Ounce), A4406 (Ostomy Skin Barrier, Pectin-Based, Paste, Per Ounce), A4407 (Ostomy Skin Barrier, With Flange (Solid, Flexible, Or Accordion), Extended Wear, With Built-In Convexity, 4 X 4 Inches Or Smaller, Each), A4408 (Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Extended Wear, With Built-In Convexity, Larger Than 4 X 4 Inches, Each), A4409 (Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Extended Wear, Without Built-In Convexity, 4 X 4 Inches Or Smaller, Each), A4410 (Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Extended Wear, Without Built-In Convexity, Larger Than 4 X 4 Inches, Each), A4411 (Ostomy Skin Barrier, Solid 4 X 4 Or Equivalent, Extended Wear, With Built-In Convexity, Each), A4412 (Ostomy Pouch, Drainable, High Output, For Use On A Barrier With Flange (2 Piece System), Without Filter, Each), A4413 (Ostomy Pouch, Drainable, High Output, For Use On A Barrier With Flange (2 Piece System), With Filter, Each), A4414 (Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Without Built-In Convexity, 4 X 4 Inches Or Smaller, Each), A4415 (Ostomy Skin Barrier, With Flange (Solid, Flexible Or Accordion), Without Built-In Convexity, Larger Than 4 X 4 Inches, Each), A4416 (Ostomy Pouch, Closed, With Barrier Attached, With Filter (1 Piece), Each), A4417 (Ostomy Pouch, Closed, With Barrier Attached, With Built-In Convexity, With Filter (1 Piece), Each), A4418 (Ostomy Pouch, Closed; Without Barrier Attached, With Filter (1 Piece), Each), A4419 (Ostomy Pouch, Closed; For Use On Barrier With Non-Locking Flange, With Filter (2 Piece), Each), A4420 (Ostomy Pouch, Closed; For Use On Barrier With Locking Flange (2 Piece), Each), A4421 (Ostomy Supply; Miscellaneous), A4422 (Ostomy Absorbent Material (Sheet/Pad/Crystal Packet) For Use In Ostomy Pouch To Thicken Liquid Stomal Output, Each), A4423 (Ostomy Pouch, Closed; For Use On Barrier With Locking Flange, With Filter (2 Piece), Each), A4424 (Ostomy Pouch, Drainable, With Barrier Attached, With Filter (1 Piece), Each), A4425 (Ostomy Pouch, Drainable; For Use On Barrier With Non-Locking Flange, With Filter (2 Piece System), Each), A4426 (Ostomy Pouch, Drainable; For Use On Barrier With Locking Flange (2 Piece System), Each), A4427 (Ostomy Pouch, Drainable; For Use On Barrier With Locking Flange, With Filter (2 Piece System), Each), A4428 (Ostomy Pouch, Urinary, With Extended Wear Barrier Attached, With Faucet-Type Tap With Valve (1 Piece), Each), A4429 (Ostomy Pouch, Urinary, With Barrier Attached, With Built-In Convexity, With Faucet-Type Tap With Valve (1 Piece), Each), A4430 (Ostomy Pouch, Urinary, With Extended Wear Barrier Attached, With Built-In Convexity, With Faucet-Type Tap With Valve (1 Piece), Each), A4431 (Ostomy Pouch, Urinary; With Barrier Attached, With Faucet-Type Tap With Valve (1 Piece), Each), A4432 (Ostomy Pouch, Urinary; For Use On Barrier With Non-Locking Flange, With Faucet-Type Tap With Valve (2 Piece), Each), A4433 (Ostomy Pouch, Urinary; For Use On Barrier With Locking Flange (2 Piece), Each), A4434 (Ostomy Pouch, Urinary; For Use On Barrier With Locking Flange, With Faucet-Type Tap With Valve (2 Piece), Each), A4435 (Ostomy Pouch, Drainable, High Output, With Extended Wear Barrier (One-Piece System), With Or Without Filter, Each), A4436 (Irrigation Supply; Sleeve, Reusable, Per Month), A4437 (Irrigation Supply; Sleeve, Disposable, Per Month), A4450 (Tape, Non-Waterproof, Per 18 Square Inches), A4452 (Tape, Waterproof, Per 18 Square Inches), A4455 (Adhesive Remover Or Solvent (For Tape, Cement Or Other Adhesive), Per Ounce), A4456 (Adhesive Remover, Wipes, Any Type, Each), A5051 (Ostomy Pouch, Closed; With Barrier Attached (1 Piece), Each), A5052 (Ostomy Pouch, Closed; Without Barrier Attached (1 Piece), Each), A5053 (Ostomy Pouch, Closed; For Use On Faceplate, Each), A5054 (Ostomy Pouch, Closed; For Use On Barrier With Flange (2 Piece), Each), A5055 (Stoma Cap), A5056 (Ostomy Pouch, Drainable, With Extended Wear Barrier Attached, With Filter, (1 Piece), Each), A5057 (Ostomy Pouch, Drainable, With Extended Wear Barrier Attached, With Built In Convexity, With Filter, (1 Piece), Each), A5061 (Ostomy Pouch, Drainable; With Barrier Attached, (1 Piece), Each), A5062 (Ostomy Pouch, Drainable; Without Barrier Attached (1 Piece), Each), A5063 (Ostomy Pouch, Drainable; For Use On Barrier With Flange (2 Piece System), Each), A5071 (Ostomy Pouch, Urinary; With Barrier Attached (1 Piece), Each), A5072 (Ostomy Pouch, Urinary; Without Barrier Attached (1 Piece), Each), A5073 (Ostomy Pouch, Urinary; For Use On Barrier With Flange (2 Piece), Each), A5081 (Stoma Plug Or Seal, Any Type), A5082 (Continent Device; Catheter For Continent Stoma), A5083 (Continent Device, Stoma Absorptive Cover For Continent Stoma), A5093 (Ostomy Accessory; Convex Insert), A5102 (Bedside Drainage Bottle With Or Without Tubing, Rigid Or Expandable, Each), A5120 (Skin Barrier, Wipes Or Swabs, Each), A5121 (Skin Barrier; Solid, 6 X 6 Or Equivalent, Each), A5122 (Skin Barrier; Solid, 8 X 8 Or Equivalent, Each), A5126 (Adhesive Or Non-Adhesive; Disk Or Foam Pad), A5131 (Appliance Cleaner, Incontinence And Ostomy Appliances, Per 16 Oz.), A6216 (Gauze, Non-Impregnated, Non-Sterile, Pad Size 16 Sq. In. Or Less, Without Adhesive Border, Each Dressing), A9270 (Non-Covered Item Or Service).
Coverage indications, limitations and medical necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
• The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
• The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
• Refer to the Supplier Manual for additional information on documentation requirements.
• Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
The quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual beneficiary need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity needed for a particular beneficiary may be more or less than the amount listed depending on the factors that affect the frequency of barrier and pouch change.
The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary’s medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary.
USUAL MAXIMUM QUANTITY OF SUPPLIES:
Code
# per Month
A4357
A4362
20
A4364
A4367
A4369
A4377
10
A4381
10
A4402
A4404
10
A4405
A4406
A4414
20
A4415
20
A4416
60
A4417
60
A4418
60
A4419
60
A4420
60
A4423
60
A4424
20
A4425
20
A4426
20
A4427
20
A4429
20
A4431
20
A4432
20
A4433
20
A4434
20
A4436
A4437
A4450
40
A4452
40
A5051
60
A5052
60
A5053
60
A5054
60
A5055
31
A5056
40
A5057
40
A5061
20
A5062
20
A5063
20
A5071
20
The policy text continues in the CMS record.
Summary of evidence (opening)
NA
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2024-01-01
- Last reviewed by the contractor
- 2019-01-08
- MCD version
- 27
- Derived from
- L11491
Other related documents: A55426 (Article).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub and CGS Administrators, LLC hub list every other active policy from the same contractor.
Frequently asked questions
What does LCD L33828 cover?
The quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual beneficiary need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually reasonable and necessary. The actual… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33828 apply to?
Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply it to Medicare claims in AK, AL, AR, AS, AZ, CA, CNMI, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33828?
The companion article article A52487 lists 10 ICD-10-CM codes in 1 group that support medical necessity; the first 10 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33828?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.