CommercialCoverageHigh impact
Ostomy Supplies (CPB 0906, reviewed 2025-12-22)
Aetna·General Surgery, Urology, Wound Care +1 more·Medical Policy
Effective date
Dec 22, 2025
We identified it
Aug 13, 2026
Summary
Aetna has issued a comprehensive medical policy (CPB 0906) establishing medical necessity criteria and monthly/semi-annual quantity limits for ostomy supplies across all ostomy types (colostomy, ileostomy, urinary ostomy). The policy specifies maximum allowable units per item, requires documentation to justify quantities exceeding limits, and restricts certain combinations (e.g., no dual use of liquid barriers, no concurrent day/night drainage bags). Claims exceeding documented medical necessity will be denied.
Action Required
By December 22, 2025 (effective immediately): Billing team must implement quantity limits in billing software for all ostomy HCPCS codes (A4331-A4409) per Table 1 (monthly) and Table 2 (semi-annual) limits. Update billing system to: (1) flag claims exceeding maximums for review; (2) require providers to submit medical necessity documentation for quantities above limits before claim submission; (3) deny or pend claims lacking documented justification. Notify providers that documentation must clearly justify excess quantities based on stoma type, location, construction, and skin condition. Train front-desk and billing staff on quantity restrictions and the prohibition of dual-use items (e.g., cannot bill both liquid and spray barriers, cannot bill both day and night drainage bags on same day for urinary ostomies). Update encounter forms to include ostomy-specific medical history fields. Failure to implement will result in claim denials and compliance violations.