`A4481` Tracheostoma filter

Tracheostoma filter, any type, any size, each

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 2 units per day (clinical), rationale: Clinical: CMS Workgroup
DME supplier: max 186 units per day (clinical), rationale: CMS Policy

Medicare pricing for A4481

DMEPOS fee schedule, July 2026 (DME26-C)

no modifier, ostomy, tracheostomy and urological (OS): non-rural $0.51 to $0.52 in the contiguous states; $0.52 to $0.77 in AK, HI, PR and VI; ceiling $0.52, floor $0.44

Physician Fee Schedule (CY 2026, RVU26D)

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

Payer policies and prior authorization for A4481

Payer coverage policies that name A4481

A4481 appears in 2 coverage policies from Aetna.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Suction Pumps (0503)	listed, no stance	Jul 2, 2026	payer document
Aetna	Tracheostomy Supplies (0074)	covered if criteria are met	Mar 18, 2026	payer document

Medicaid fee-for-service

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

AZ: $0.62 (dme), effective Oct 1, 2026
CO: $0.42 (chp_plus, non-facility), effective Jul 1, 2026
IL: $0.36 (dme), effective Jan 1, 2026
IN: $0.43 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KY: $0.37 (dme), effective Jan 1, 2026
LA: $0.28 (dme), effective Sep 1, 2021
MA: $0.42 (dme_rates), effective Mar 1, 2026
MD: $0.43 (dme), effective Apr 1, 2026
MS: $0.42 (comprehensive), effective Jul 1, 2026
ND: $0.00 (dme), effective Aug 1, 2026
NE: $0.46 (dme), effective Jul 1, 2026
NY: $2.76 (dme), effective Jul 1, 2026
OH: $0.35 (dme), effective Jan 1, 2024
OK: $0.52 (dme), effective Jan 1, 2026
TX: $0.37 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective May 1, 2003
VA: $0.46 (dme), effective Dec 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 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.

A4481 Tracheostoma filter