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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules state that the following are coding guidelines for ostomy supplies: 

BARRIERS: 

A solid barrier (wafer) is an interface between the beneficiary's skin and the pouching system, has measurable thickness and has an adhesive property. Barriers may be integrated into a "1 piece" pouch, they may be manufactured with a flange and be part of a "2 piece" pouch system (skin barrier with flange, e.g., A4414), or they may be used independently (e.g., A4362), usually with a pouch that does not have its own integral skin barrier. An extended wear barrier (e.g., A4409) is a pectin-based barrier with special additives which achieve a stronger adhesive seal, resist breakdown by urine or bowel effluent, permit longer wear times between changes, and normal wear times for those who cannot achieve them with standard barriers. There are distinct codes for extended wear compared to standard wear barriers. 

A barrier with built-in convexity (e.g., A4407 or A4411) is one in which an outward curve is usually achieved with plastic embedded in the barrier, allowing better protrusion of the stoma and adherence to the skin. There are distinct codes for barriers with built-in convexity compared to flat barriers. 

Ostomy skin barriers greater than 4x4 inches (e.g., A4408) refer to the size of the skin barriers themselves, and not to the area of any surrounding tape. 

FACEPLATES: 

A faceplate is a solid interface between the beneficiary's skin and the pouch. It is usually made of plastic, rubber or encased metal. It does not have an adhesive property and there is no pectin-based or karaya material that is an integral part of a faceplate. It can be taken off the skin and reattached repeatedly. It is secured by means of a separate adhesive and/or an elastic belt. The clips for attaching the belt are usually a part of the faceplate. There is no coding distinction between flat and convex faceplates. 

The following table lists codes for faceplate systems. When supplying a pouch with faceplate attached (Column I) a claim may not be made for a component product from Column II provided at the same time.

POUCHES: 

A pouch is a device for collecting stomal output. A pouch for collecting bowel effluent may be either "drainable" with an opening at the bottom through which the fecal contents are emptied, or 'closed' with a sealed bottom and no outlet. A "urinary" pouch normally incorporates anti-reflux devices and a tap or spigot to empty the urine contents. 

A pouch "with barrier attached" is one type of "1 piece" system in which a solid barrier is part of the pouch. There are distinct codes for 1-piece pouches with convex barriers and extended wear barriers (see "Barriers"). 

A pouch "without barrier attached" is a pouch with or without a thin adhesive coating that is applied either directly to the skin or to a separate barrier. It is also described as a "1 piece" system. 

A pouch, which is part of a "2 piece" system, has a flange, which enables it to be coupled to a skin barrier with flange. 

A pouch "with faceplate attached" or "for use on a faceplate" is generally rubber or heavy plastic. It is drainable, cleanable, and reusable for periods of weeks to months, depending on the product. 

A "high output" pouch (A4412, A4413, A4435) has a capacity of greater than or equal to 0.75 liters, is drainable with a large bore solid spout with cap or plug, and is either part of a 2 piece system (A4412, A4413) or a single-piece system (A4435). 

Codes for pouches with filters (e.g., A4416) describe pouches that have an opening which allows venting of trapped gas. They typically include materials such as charcoal to deodorize the vented gas. Code A4368 describes replacement filter material. 

Code A4366 describes a separate ostomy vent that can be added by the beneficiary to a pouch to allow the release of gas. This code must not be used for pouches in which a vent with a filter is incorporated in the pouch by the manufacturer. Those products are described by the codes for ostomy pouches with a filter (A4416, A4417, A4418, A4419, A4423, A4424, A4425, A4427). 

Absorbent material (A4422) that is added to the ostomy pouch may come as sheets, pads or crystals. 

An ostomy pouch with faucet-type tap with valve (e.g., A4429) has a valve for draining urine. 

A locking flange (e.g., A4420) is a lever type flange locking mechanism. It differs from simple push-on pouch securing mechanisms. The mechanism may be incorporated either in the pouch flange or skin barrier flange (2 piece system). 

PASTES: 

A paste is used as a protective layer and sealant beneath ostomy appliances, and is applied directly on the skin. It may be primarily pectin based (A4406), or non-pectin based, e.g., karaya (A4405). 

MISCELLANEOUS: 

Code A4400 (Ostomy irrigation set) is not valid for claim submission. If an irrigation kit is supplied, the individual components should be billed using individual codes, A4397, A4398, and A4399.

Ostomy clamps (A4363) are used with drainable pouches and are not used with urinary pouches. Ostomy clamps are only payable when ordered as a replacement. Claims for ostomy clamps billed with ostomy pouches will be denied as not separately payable with ostomy pouches. 

When codes A4450, A4452, and A5120 are used with ostomy supplies, they must be billed with the AU modifier. For this policy, codes A4450, A4452, and A5120 are the only codes for which the AU modifier may be used. 

You can find these rules in the Local Coverage Article, Ostomy Supplies - Policy Article, A52487.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.