Consumable Medical Supplies

Reimbursement Policy:
Consumable Medical Supplies

Effective Date:
May 1, 2016

Purpose:
Provide clarification of the standard Horizon benefit contract exclusions relative to consumable medical supplies using specific codes and examples.

Scope:
All plans/products that include the following standard Horizon benefit contract exclusions are considered in scope.

Non-HMO Individual Consumer and Small Group Employer (2-49 employees) plans:

  • Non-prescription drugs or supplies, except
    • insulin needles and syringes and glucose test strips and lancets;
    • colostomy bags, belts and irrigators; and
    • as stated in this Policy for food and food products for inherited metabolic diseases.
  • Personal convenience or comfort items including, but not limited to, such items as TV's, telephones, first aid kits, exercise equipment, air conditioners, humidifiers, saunas, hot tubs.
  • Self-administered services such as: biofeedback, patient-controlled analgesia on an Outpatient basis, related diagnostic testing, self-care and self-help training.
  • Services or supplies that are not furnished by an eligible Provider.

HMO Individual Consumer and Small Group Employer (2-49 employees) plans:

  • Non-prescription drugs or supplies, except
    • insulin needles and syringes and glucose test strips and lancets;
    • colostomy bags, belts and irrigators; and
    • as stated in this Policy for food and food products for inherited metabolic diseases.
  • Personal convenience or comfort items including, but not limited to, such items as TV's, telephones, first aid kits, exercise equipment, air conditioners, humidifiers, saunas, hot tubs.
  • Self-administered services such as: biofeedback, patient-controlled analgesia on an Outpatient basis, related diagnostic testing, self-care and self-help training.

Non-HMO Large Group Employer (51+ employees) plans:

  • Ancillary charges connected with self-administered services such as: patient-controlled analgesia; related diagnostic testing; self-care; and self-help training
  • Consumable medical supplies
  • Non-Medical equipment which may be used chiefly for personal hygiene or for the comfort or convenience if a covered person rather than for medical purpose. This includes: air conditioners, dehumidifiers, purifiers, saunas, hot tubs; televisions, telephones, first aid kits, exercise equipment, heating pads; and such similar supplies which are useful to a person in the absence of Illness or Injury.
  • Personal comfort and convenience items.

HMO Large Group Employer (51+ employees) plans:

  • Self-administered services such as: biofeedback, patient-controlled analgesia, related diagnostic testing, self-care and self-help training.
  • Non‑medical equipment which is primarily for personal hygiene or for comfort or convenience rather than for a medical purpose, including air conditioners, dehumidifiers, purifiers, heating pads and similar supplies which are useful to a person in the absence of Illness or Injury or other condition.
  • Services and supplies for the personal convenience or comfort of the Member, including, but not limited to, such items as televisions, telephones, first aid kits, exercise equipment, air conditioners, humidifiers, saunas and hot tubs.

Policy:
Consumable medical supplies are non-durable medical supplies that cannot withstand repeated use, are usually disposable, and are generally not used in the absence of illness or injury. They include, but are not limited to, bandages, antiseptics, and skin preparations.

Horizon BCBSNJ will not reimburse claims submitted for consumable medical supplies including, but not limited to, items represented by the HCPCS codes below, and as consistent with the general exclusion language present in all member benefit contracts that include those exclusions detailed in the Scope section above.1

Code Description
A4244 Alcohol or peroxide, per pint
A4246 Betadine or phisohex solution, per pint
A4247 Betadine or iodine swabs/wipes, per box
A4248 Chlorhexidine containing antiseptic, 1 ml
A4450 Tape, nonwaterproof, per 18 sq in
A4452 Tape, waterproof, per 18 sq in
A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per oz
A4456 Adhesive remover, wipes, any type, each
A4458 Enema bag with tubing, reusable
A4461 Surgical dressing holder, nonreusable, each
A4463 Surgical dressing holder, reusable, each
A4465 Nonelastic binder for extremity
A4466 Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each
A4490 Surgical stocking above knee length, each
A4495 Surgical stocking thigh length, each
A4500 Surgical stocking below knee length, each
A4510 Surgical stocking full-length, each
A4520 Incontinence garment, any type, (e.g. brief, diaper), each
A4554 Disposable underpads, all sizes
A4930 Gloves, sterile, per pair
A4931 Oral thermometer, reusable, any type, each
A6216 Gauze, nonimpregnated, nonsterile, pad size 16 sq in or less, without adhesive border, each dressing
A6217 Gauze, nonimpregnated, nonsterile, pad size more than 16 sq in but less than or equal to 48 sq in, without adhesive border, each dressing
A6218 Gauze, nonimpregnated, nonsterile, pad size more than 48 sq in, without adhesive border, each dressing
A6219 Gauze, nonimpregnated, sterile, pad size 16 sq in or less, with any size adhesive border, each dressing
A6220 Gauze, nonimpregnated, sterile, pad size more than 16 sq in but less than or equal to 48 sq in, with any size adhesive border, each dressing
A6221 Gauze, nonimpregnated, sterile, pad size more than 48 sq in, with any size adhesive border, each dressing
A6250 Skin sealants, protectants, moisturizers, ointments, any type, any size
A6257 Transparent film, sterile, 16 sq in or less, each dressing
A6258 Transparent film, sterile, more than 16 sq in but less than or equal to 48 sq in, each dressing
A6259 Transparent film, sterile, more than 48 sq in, each dressing
A6402 Gauze, nonimpregnated, sterile, pad size 16 sq in or less, without adhesive border, each dressing
A6403 Gauze, nonimpregnated, sterile, pad size more than 16 sq in, less than or equal to 48 sq in, without adhesive border, each dressing
A6404 Gauze, nonimpregnated, sterile, pad size more than 48 sq in, without adhesive border, each dressing
A6411 Eye pad, non-sterile, each
A6412 Eye patch, occlusive, each
A6413 Adhesive bandage, first aid type, any size, each
A6441 Padding bandage, nonelastic, nonwoven/nonknitted, width greater than or equal to 3 in and less than 5 in, per yd
A6442 Conforming bandage, nonelastic, knitted/woven, nonsterile, width less than 3 in, per yd
A6443 Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to 3 in and less than 5 in, per yd
A6444 Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to 5 in, per yd
A6445 Conforming bandage, nonelastic, knitted/woven, sterile, width less than 3 in, per yd
A6446 Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to 3 in and less than 5 in, per yd
A6447 Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to 5 in, per yd
A6453 Self-adherent bandage, elastic, nonknitted/nonwoven, width less than 3 in, per yd
A6454 Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to 3 in and less than 5 in, per yd
A6455 Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to 5 in, per yd
A6457 Tubular dressing with or without elastic, any width, per linear yard
A9273 Hot water bottle, ice cap or collar, heat and/or cold wrap, any type

1 As of the Effective Date, systemic claims coding was reviewed and confirmed to be consistent with this Policy.

The codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued, until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Maintain the plan general exclusion (PGE) edit on consumable medical supplies, including but not limited to the HCPCS codes listed in the examples above.

In denied instances where the provider is participating, it is generally not expected that the provider will bill the member for these consumable items, however, if they do, the member’s liability shall be up to the provider’s charge.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:
Consumable medical supplies provided in conjunction with DME are covered if the supplies are necessary for the function of the equipment and the equipment is covered under the plan. Examples include ostomy and ventilator supplies.

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

The following categories of consumable medical supplies may be eligible for coverage according to federal or state mandates, or current industry standards:

  • Diabetes supplies, including alcohol wipes, lancets, test strips, syringes and needles
  • Surgical wound care supplies, including gauze pads, wound cleansers, and compression bandages
  • Inpatient hospital services;
  • Outpatient hospital facility services;
  • Home health services;
  • Breast reconstruction and breast prostheses

Policy100_V1.0_08082016