HCPCS Level II › A codes A6454 Self-adher band w>=3" <5"/ydSelf-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard
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 25 units per day (clinical), rationale: Clinical: Data Medicare pricing for A6454 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, surgical dressings (SD): non-rural $1.12 in the contiguous states; $1.12 to $1.29 in AK, HI, PR and VI; ceiling $1.12, floor $0.95 Physician Fee Schedule (CY 2026, RVU26D) Status X: statutory exclusion, not paid under the PFS.
Payer policies and prior authorization for A6454 Payer coverage policies that name A6454 A6454 appears in 3 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Dialysis (0541) covered if criteria are met (range A6010-A6457) Aug 26, 2026 payer document Aetna Surgical Devices, Dressings, and Wound Care Supplies (0526) covered if criteria are met (range A6453-A6455) Aug 26, 2026 payer document Aetna Urological Supplies (0533) not covered (range A6453-A6455) Jul 30, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in CO, KY, MA, OH, VA, WV.
AZ: $1.34 (dme), effective Oct 1, 2026 CO: $0.92 (chp_plus, non-facility), effective Jul 1, 2026 FL: $0.54 (dme), effective Jul 1, 2026 IL: $0.73 (dme), effective Jan 1, 2026 IN: $0.94 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $0.90 (default), effective Jul 1, 2026 KY: $0.62 (dme), effective Jan 1, 2026 MA: $0.91 (dme_rates), effective Mar 1, 2026 MD: $0.95 (dme), effective Apr 1, 2026 MS: $0.90 (comprehensive), effective Jul 1, 2026 ND: $1.36 (dme), effective Aug 1, 2026 NE: $0.97 (dme), effective Jul 1, 2026 NY: $0.58 (dme), effective Jul 1, 2026 OH: $0.69 (dme), effective Oct 1, 2004 OK: $1.12 (dme), effective Jan 1, 2026 TX: $0.70 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective Jul 1, 2004 VA: $1.01 (dme), effective Dec 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $0.83 (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.