Consumable Medical Supplies
Reimbursement Policy:
Consumable Medical Supplies
Effective Date:
May 1, 2016
Last Reviewed Date:
February 23, 2023
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 and personal protective equipment (PPE) such as masks (community and medical/surgical), goggles, face shields/safety visors, respirators (N95 and filtering face piece), gloves (examination and surgical), gowns, garments, coveralls, and clean air suits.
Additionally, PPE products used while examining or treating a patient in an Office, Urgent Care Center; Surgical Center; Home or other setting will not be considered for separate reimbursement.
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 |
A4467 | Belt, strap, sleeve, garment, or covering, any type |
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 |
A4927 | Gloves, nonsterile, per 100 |
A4928 | Surgical mask, per 20 |
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 |
A9270 | Non-covered item or service |
A9273 | Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type |
A9999 | Miscellaneous DME supply or accessory, not otherwise specified |
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
- 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
History:
1/10/2018: Removed deleted HCPCS code A4466
7/27/2020: Added HCPCS codes A4927, A4928, A9270, A9999. Updated policy section on PPE equipment
2/28/2022: Corrected descriptions of codes A6457, A9270 and A9273 within Policy: section table.
Policy100_v4.0_02232023