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.
· Pouches (Closed) 60 per Month
· Pouches (Drainable) 20 per Month
· Pouches (Urinary) 20 per Month
· Wafers (4 x 4) 20 per Month
· Wafers (6 x 6) 20 per Month
· Wafers (8 x 8) 20 per Month
· Stoma Cap 31 per month
· Lubricant 4 oz per Month
· Irrigation cone/bag 1 every 3 Months
· Irrigation Sleeve 4 per Month
· Stomahesive Paste 8 oz per Month
· Adhesive 8 oz per Month
· Adhesive Remover (liquid) 8 oz per Month
· Adhesive Remover (wipes) 75 per Month
· Convex Inserts 10 per Month
· Ostomy Belt 1 per Month
· Appliance Cleaner 16 oz per Month
· Tape (depending on width) 1-2 rolls per Month
· Skin Barrier Wipes 75 per Month
· Ostomy Deodorant 8 oz per Month
· Drainage Bottle 1 every 3 Months
· Drainage bag 2 per Month
· Ostomy absorbent packets 90 per Month
· Non sterile gauze 16 sq in or less 60 per Month