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Issue Number - Name
0103-Complex Urological Supplies
Review Type
Claim Type
DME by Supplier, DME by Physician
Region and State
All States
Date Approved


Documentation will be reviewed to determine if the Urological Supplies meet coverage criteria and are medically reasonable and necessary.

Affected Code(s)

  • A4217, A4310-A4316, A4320-A4322, A4326-A4328, A4331-A4336, A4338, A4340, A4344, A4346, A4349, A4351-A4358, A4360, A4402, A4450,  A4452, A4455, A4456, A4520, A4553, A4554, A5102, A5105, A5112-A5114, A5131, A5200, A9270

Applicable Policy References

  • Social Security Act, Section 1862(a)(1)(A)
  • Social Security Act, Section 1861(s)(8)
  • 42 CFR 424.57(c)(12)
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.1-8, 5.3, 5.8
  • Local Coverage Determination, L33803, Effective date 10/01/2015 
  • Local Coverage Article, A52521, Effective date 10/01/2015
  • Local Coverage Article, A55426, Effective date 01/01/2017