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 A52492 (Tracheostomy Care 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.
A52492: Tracheostomy Care Supplies - Policy Article (Article, effective 2020-01-01)
- 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) |
|---|---|
| J95.00 | — |
| J95.01 | — |
| J95.02 | — |
| J95.03 | — |
| J95.04 | — |
| J95.09 | — |
| Z43.0 | — |
| Z90.02 | — |
| Z93.0 | — |
| Z96.3 | — |
Procedure codes named in the LCD
A4364 (Adhesive, Liquid Or Equal, Any Type, Per Oz), A4402 (Lubricant, Per Ounce), A4450 (Tape, Non-Waterproof, Per 18 Square Inches), A4452 (Tape, Waterproof, Per 18 Square Inches), A4456 (Adhesive Remover, Wipes, Any Type, Each), A4481 (Tracheostoma Filter, Any Type, Any Size, Each), A4623 (Tracheostomy, Inner Cannula), A4625 (Tracheostomy Care Kit For New Tracheostomy), A4626 (Tracheostomy Cleaning Brush, Each), A4629 (Tracheostomy Care Kit For Established Tracheostomy), A5120 (Skin Barrier, Wipes Or Swabs, Each), A5126 (Adhesive Or Non-Adhesive; Disk Or Foam Pad), A7501 (Tracheostoma Valve, Including Diaphragm, Each), A7502 (Replacement Diaphragm/Faceplate For Tracheostoma Valve, Each), A7503 (Filter Holder Or Filter Cap, Reusable, For Use In A Tracheostoma Heat And Moisture Exchange System, Each), A7504 (Filter For Use In A Tracheostoma Heat And Moisture Exchange System, Each), A7505 (Housing, Reusable Without Adhesive, For Use In A Heat And Moisture Exchange System And/Or With A Tracheostoma Valve, Each), A7506 (Adhesive Disc For Use In A Heat And Moisture Exchange System And/Or With Tracheostoma Valve, Any Type Each), A7507 (Filter Holder And Integrated Filter Without Adhesive, For Use In A Tracheostoma Heat And Moisture Exchange System, Each), A7508 (Housing And Integrated Adhesive, For Use In A Tracheostoma Heat And Moisture Exchange System And/Or With A Tracheostoma Valve, Each), A7509 (Filter Holder And Integrated Filter Housing, And Adhesive, For Use As A Tracheostoma Heat And Moisture Exchange System, Each), A7520 (Tracheostomy/Laryngectomy Tube, Non-Cuffed, Polyvinylchloride (Pvc), Silicone Or Equal, Each), A7521 (Tracheostomy/Laryngectomy Tube, Cuffed, Polyvinylchloride (Pvc), Silicone Or Equal, Each), A7522 (Tracheostomy/Laryngectomy Tube, Stainless Steel Or Equal (Sterilizable And Reusable), Each), A7523 (Tracheostomy Shower Protector, Each), A7524 (Tracheostoma Stent/Stud/Button, Each), A7526 (Tracheostomy Tube Collar/Holder, Each), A7527 (Tracheostomy/Laryngectomy Tube Plug/Stop, Each).
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.
Refer to the Nonmedical Necessity Coverage and Payment Rules section of the related Policy Article for information about the statutory coverage requirements for tracheostomy supplies.
A tracheostomy care or cleaning starter kit (A4625) is covered following an open surgical tracheostomy. Beginning two weeks post-operatively, code A4625 is no longer medically necessary and, if that code is billed, will be denied as not reasonable and necessary.
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 clinical factors that affect the frequency of supply changes.
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(unless noted)
A4364
A4402
A4450
40
A4452
40
A4456
50
A4481
62
A4623
62
A4625
31
A4626
A4629
31
A5120
150
A7501
A7502
A7503
1 per 6 months
A7504
62
A7505
2 per 3 months
A7506
62
A7507
62
A7508
62
A7509
62
A7520
1 per 3 months
A7521
1 per 3 months
A7522
1 per 12 months
A7524
1 per 3 months
A7526
31
A7527
2 per 3 months
A7523 is a convenience item and therefore not covered. Claims for A7523 will be denied as not reasonable and necessary.
A7527 (Tracheostomy/laryngectomy tube plug/stop) is used as an alternative to a tracheostomy/laryngectomy tube and therefore for a beneficiary receiving A7527 claims for A7520, A7521 and A7522 will be denied as not reasonable or necessary.
GENERAL
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
REFILL REQUIREMENTS
For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary, and document an affirmative response, prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are expected to end, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 30 calendar days prior to the expected end of the current supply. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the expected end of the current supply. This is regardless of which delivery method is utilized.
For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the beneficiary or caregiver/designee and document an affirmative response, prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request and an affirmative response from a beneficiary. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.
Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating practitioners that any changed or atypical utilization is warranted.
Regardless of utilization, a supplier must not dispense more than a 1-month supply at a time for a beneficiary in a nursing facility and a 3-month supply for a beneficiary at home.
For information on tracheal suction catheters and related supplies, see the Suction Pump policy.
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
- 20
- Derived from
- L166
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 L33832 cover?
Refer to the Nonmedical Necessity Coverage and Payment Rules section of the related Policy Article for information about the statutory coverage requirements for tracheostomy supplies. 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 L33832 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 L33832?
The companion article article A52492 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 L33832?
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.