A4390 Drainable pch ex wear convex

Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each

Medically Unlikely Edits (effective October 1, 2026)

Medicare pricing for A4390

DMEPOS fee schedule, July 2026 (DME26-C)

Physician Fee Schedule (CY 2026, RVU26D)

Status X: statutory exclusion, not paid under the PFS.

Payer policies and prior authorization for A4390

Payer coverage policies that name A4390

A4390 appears in 1 coverage policy from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaOstomy Supplies (0906)covered if criteria are metDec 22, 2025payer document

Medicaid fee-for-service

Prior authorization required or conditional in KY, LA, MA, NY, OH, VA, WV.

  • AZ: $14.70 (dme), effective Oct 1, 2026
  • CO: $9.39 (chp_plus, non-facility), effective Jul 1, 2026
  • FL: $7.87 (dme), effective Jul 1, 2026
  • IL: $8.71 (dme), effective Jan 1, 2026
  • IN: $6.47 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2014
  • KS: $10.94 (default), effective Jul 1, 2026
  • KY: $9.61 (dme), effective Jan 1, 2026
  • MA: $11.14 (dme_rates), effective Mar 1, 2026
  • MD: $11.63 (dme), effective Apr 1, 2026
  • MS: $10.94 (comprehensive), effective Jul 1, 2026
  • ND: $0.00 (dme), effective Aug 1, 2026
  • NE: $11.97 (dme), effective Jul 1, 2026
  • NY: $8.49 (dme), effective Jul 1, 2026
  • OH: $8.94 (dme), effective Apr 1, 2001
  • OK: $13.68 (dme), effective Jan 1, 2026
  • TX: $9.17 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective Feb 1, 2000
  • VA: $12.31 (dme), effective Dec 1, 2026
  • VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $10.29 (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.