HCPCS Level II › A codes A4244 Alcohol or peroxide per pintAlcohol or peroxide, per pint
Medicare coverage: Carrier judgment 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 1 units per day (clinical), rationale: Clinical: Data DME supplier: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for A4244 Physician Fee Schedule (CY 2026, RVU26D) Status X: statutory exclusion, not paid under the PFS.
Payer policies and prior authorization for A4244 Payer coverage policies that name A4244 A4244 appears in 2 coverage policies from Aetna, Premera Blue Cross.
Payer Policy Role in policy Reviewed Document Aetna Diabetes Tests, Programs and Supplies (0070) covered if criteria are met Feb 20, 2026 payer document Premera Blue Cross Non-covered Services and Procedures listed, no stance Jun 1, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in CO, KY, LA, MA, OH, VA, WV.
AZ: $4.01 (outpatient_hospital), effective Oct 1, 2011 CO: $0.58 (chp_plus, non-facility), effective Jul 1, 2026 FL: $0.84 (dme), effective Jul 1, 2026 IN: $1.45 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $0.85 (default), effective Jun 1, 2007 KY: $0.99 (dme), effective Jan 1, 2026 MA: $1.27 (dme_rates), effective Mar 1, 2026 MS: $0.65 (comprehensive), effective Jul 1, 2026 ND: $4.19 (dme), effective Aug 1, 2026 NE: $4.65 (dme), effective Jul 1, 2026 NY: $1.13 (dme), effective Jul 1, 2026 OH: $0.56 (dme), effective May 1, 1990 OK: $0.60 (dme), effective Aug 1, 2020 TX: $0.85 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Apr 1, 2019 VA: $0.65 (medical), effective Jul 1, 2010 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $1.02 (medical_equipment_supplies), effective Jul 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026 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.