Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)
Medically Unlikely Edits (effective October 1, 2026)
Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 4 units per day (clinical), rationale: Clinical: CMS Workgroup
Medicare pricing for A4217
DMEPOS fee schedule, July 2026 (DME26-C)
no modifier, supplies (SU): non-rural $3.80 to $4.47 in the contiguous states; $2.18 to $4.93 in AK, HI, PR and VI; ceiling $4.47, floor $3.80
AU, ostomy, tracheostomy and urological (OS): non-rural $3.80 to $4.47 in the contiguous states; $2.18 to $4.93 in AK, HI, PR and VI; ceiling $4.47, floor $3.80
Physician Fee Schedule (CY 2026, RVU26D)
Status X: statutory exclusion, not paid under the PFS.
Payer policies and prior authorization for A4217
Payer coverage policies that name A4217
A4217 appears in 5 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.