Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each
Medicare coverage: Carrier judgment
Status: active (October 2026 file)
Medically Unlikely Edits (effective October 1, 2026)
Practitioner: max 2 units per day (clinical), rationale: Clinical: CMS Workgroup
Outpatient hospital: max 2 units per day (clinical), rationale: Clinical: CMS Workgroup
Medicare pricing for A4417
DMEPOS fee schedule, July 2026 (DME26-C)
no modifier, ostomy, tracheostomy and urological (OS): non-rural $5.31 in the contiguous states; $5.31 to $5.78 in AK, HI, PR and VI; ceiling $5.31, floor $4.51
Physician Fee Schedule (CY 2026, RVU26D)
Status X: statutory exclusion, not paid under the PFS.
Payer policies and prior authorization for A4417
1 of 1 payer prior-auth lists that name A4417 require prior authorization or set conditions: Passport by Molina Healthcare (Kentucky).
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.