Medicare Advantage

Medical Policy

Notification

Tracheostomy Care Supplies

Notification Issue Date:

This version of the policy will become effective 05/06/2024.

In accordance with Medicare, the timelines for refill requirements were revised and Coverage for NOC (not otherwise classified) code S8189 changed from Medically Necessary to Not Covered.

The following billing requirement has been added to the policy:

An AU modifier must be used when codes A4450, A4452 and A5120 are billed with tracheostomy care supplies

Title:

Tracheostomy Care Supplies

Policy #:

MA05.034a

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

MEDICALLY NECESSARY

A tracheostomy care or cleaning starter kit for a new tracheostomy (A4625) is considered medically necessary and, therefore, covered following an open surgical tracheostomy. Beginning 2 weeks postoperatively, a tracheostomy care or cleaning starter kit for a new tracheostomy (A4625) is no longer medically necessary and, therefore, not covered because a tracheostomy care kit for an established tracheostomy (A4629) would be appropriate.

A tracheostomy speaking valve (L8501) is considered medically necessary and, therefore, covered as an add-on to the trachea tube.

Supplies for care of a tracheostomy site are considered medically necessary and, therefore, covered for an individual following an open surgical tracheostomy that has been open or is expected to remain open for at least 3 months.

The table below lists the maximum number of items/units of service that are usually medically necessary. The actual quantity needed for a particular individual may be more or less than the amount listed depending on clinical factors that affect the frequency of supply changes.

Code	Number per Month (unless noted)
A4364	4
A4402	4
A4450	40
A4452	40
A4456	50
A4481	62
A4623	62
A4625	31
A4626	2
A4629	31
A5120	150
A7501	1
A7502	1
A7503	1 per 6 months
A7504	62
A7505	2 per 3 months
A7506	62
A7507	62
A7508	62
A7509	62
A7520	1 per 3 months
A7521	1 per 3 months
A7522	1 per 12 months
A7524	1 per 3 months
A7526	31
A7527	2 per 3 months

NOT MEDICALLY NECESSARY

The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the individual's medical record. If adequate documentation is not provided when requested, the excess quantities will be considered not medically necessary and, therefore, not covered.

A tracheostomy/laryngectomy tube plug/stop (A7527) is used as an alternative to a tracheostomy/laryngectomy tube (A7520, A7521, A7522). For an individual receiving a tracheostomy/laryngectomy tube plug/stop (A7527), a tracheostomy tube (A7520, A7521 and A7522) is considered not medically necessary and, therefore, not covered.

NOT COVERED

A tracheostomy shower protector (A7523) is not covered by the Company because it is an item not covered by Medicare because it is a convenience item. Therefore, it is not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

STANDARD WRITTEN ORDER REQUIREMENTS

Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file. 

PROOF OF DELIVERY REQUIREMENTS

Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)

The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than 30 calendar days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual's medical record. Delivery of the supplies should not be done earlier than 10 calendar days before the individual would exhaust their current supply.

The DME supplier must not dispense more than a 1-month supply for an individual in a nursing facility and a 3-month supply for an individual at home.​

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.

BILLING REQUIREMENTS

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
 
A tracheostomy care or cleaning starter kit (A4625) contains the following:
 
Item ​Number Included
Plastic tray1
Basin1
Sterile gloves1 pair
Tube brush1
Pipe cleaners3
Pre-cut tracheostomy dressing1
Gauze1 roll
4 × 4 sponges4
Cotton tip applicators2
Twill tape30 inches

A tracheostomy care kit for an established tracheostomy (A4629) contains the following:
 
Item Number Included
Tube brush1
Pipe cleaners2
Cotton tip applicators2
Twill tape30 inches
4 ×​ 4 sponges2
 
The quantities of supplies included in a tracheostomy care kit are to provide all necessary quantities for the care of the tracheostomy site, and there must not be any additional quantity billed of these codes for this purpose. Additional supplies may be billed, as appropriate and necessary, only for care other than for a tracheostomy site, such as for speaking valves.

COLUMN I/COLUMN II REIMBURSEMENT EDITS

The reimbursement for the item represented by the code in column II is included in the reimbursement for the item represented by the code in column I when provided at the same time.
 
Column I Column II
A4625A4626
A4629A4626
 
​An AU modifier must be used when codes A4450, A4452 and A5120 are billed with tracheostomy care supplies.​

Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, tracheostomy care supplies are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

A tracheostomy is a surgically made opening that goes through the front of an individual's neck and into the trachea. It provides an air passage to assist with breathing when the usual route for breathing is obstructed or impaired.

References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 50.4: Tracheostomy speaking valve. [CMS Web site]. 09/09/88. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=247&ncdver=1&bc=AAAAgAAAAAAAAA==&. Accessed December 04, 2025.

Noridian Healthcare Solutions LLC. Local Coverage Determination (LCD). L33832: Tracheostomy Care Supplies. [Noridian Healthcare Solutions Web site]. Effective Date 10/01/2015. Revision Effective Date 01/01/2024. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33832. Accessed December 04, 2025.

Noridian Healthcare Solutions LLC. Local Coverage Article (LCA). A52492: Tracheostomy Care Supplies-Policy Article. [Noridian Healthcare Solutions Web site]. Effective Date 10/01/2015. Revision Effective Date 01/01/2020. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52492&ver=20. Accessed December 04, 2025.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

J95.00 Unspecified tracheostomy complication

J95.01 Hemorrhage from tracheostomy stoma

J95.02 Infection of tracheostomy stoma

J95.03 Malfunction of tracheostomy stoma

J95.04 Tracheo-esophageal fistula following tracheostomy

J95.09 Other tracheostomy complication

Z43.0 Encounter for attention to tracheostomy

Z93.0 Tracheostomy status

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

A4364 Adhesive, liquid or equal, any type, per oz

A4402 Lubricant, per oz

A4450 Tape, nonwaterproof, per 18 sq in

A4452 Tape, waterproof, per 18 sq in

A4456 Adhesive remover, wipes, any type, each

A4481 Tracheostoma filter, any type, any size, each

A4623 Tracheostomy, inner cannula

A4625 Tracheostomy care kit for new tracheostomy

A4626 Tracheostomy cleaning brush, each

A4629 Tracheostomy care kit for established tracheostomy

A5120 Skin barrier, wipes or swabs, each

A7501 Tracheostoma valve, including diaphragm, each

A7502 Replacement diaphragm/faceplate for tracheostoma valve, each

A7503 Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each

A7504 Filter for use in a tracheostoma heat and moisture exchange system, each

A7505 Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each

A7506 Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each

A7507 Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each

A7508 Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each

A7509 Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each

A7520 Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each

A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each

A7522 Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each

A7524 Tracheostoma stent/stud/button, each

A7525 Tracheostomy mask, each

A7526 Tracheostomy tube collar/holder, each

A7527 Tracheostomy/laryngectomy tube plug/stop, each

L8501 Tracheostomy speaking valve

NOT COVERED

A7523 Tracheostomy shower protector, each

S8189 Tracheostomy supply, not otherwise classified

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifier

AU Item furnished in conjunction with a urological, ostomy or tracheostomy supply

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA05.034a:

03/04/2026	This version of the policy will become effective 03/04/2026. The policy has been reviewed and reissued to communicate the Company's continuing position on tracheostomy care supplies.
04/02/2025	This policy has been reissued in accordance with the Company's annual review process.

05/06/2024