A5054 — Ostomy pouch, closed; for use on barrier with flange (2 piece), each
HCPCS Level II A-code · short descriptor: “Clsd ostomy pouch w/flange”
- Code system
- HCPCS Level II
- Family
- A — Medical & surgical supplies, ambulance
- Medicare coverage status
- Special coverage instructions apply
- DMEPOS payment category
- Ostomy, tracheostomy & urological supplies
- Prior authorization
- Not on Medicare required-PA list
- Status
- Active (April 2026 HCPCS)
Prior authorization
Not on the Medicare required-PA list as of the January 13, 2026 update (74 items). Medicare Advantage and commercial plans set their own prior-authorization rules for this code — verify per plan before delivery.
A5054 Medicare fee schedule (April 2026)
Base (no modifier) Ostomy, tracheostomy & urological supplies
Medicare allowable ranges from $2.56 to $3.04 depending on state and rural status.
Former-CBA payment limits: ceiling $2.56 · floor $2.18
| State | Non-rural | Rural |
|---|---|---|
| AK | $2.56 | — |
| AL | $2.56 | — |
| AR | $2.56 | — |
| AZ | $2.56 | — |
| CA | $2.56 | — |
| CO | $2.56 | — |
| CT | $2.56 | — |
| DC | $2.56 | — |
| DE | $2.56 | — |
| FL | $2.56 | — |
| GA | $2.56 | — |
| HI | $2.56 | — |
| IA | $2.56 | — |
| ID | $2.56 | — |
| IL | $2.56 | — |
| IN | $2.56 | — |
| KS | $2.56 | — |
| KY | $2.56 | — |
| LA | $2.56 | — |
| MA | $2.56 | — |
| MD | $2.56 | — |
| ME | $2.56 | — |
| MI | $2.56 | — |
| MN | $2.56 | — |
| MO | $2.56 | — |
| MS | $2.56 | — |
| MT | $2.56 | — |
| NC | $2.56 | — |
| ND | $2.56 | — |
| NE | $2.56 | — |
| NH | $2.56 | — |
| NJ | $2.56 | — |
| NM | $2.56 | — |
| NV | $2.56 | — |
| NY | $2.56 | — |
| OH | $2.56 | — |
| OK | $2.56 | — |
| OR | $2.56 | — |
| PA | $2.56 | — |
| PR | $3.04 | — |
| RI | $2.56 | — |
| SC | $2.56 | — |
| SD | $2.56 | — |
| TN | $2.56 | — |
| TX | $2.56 | — |
| UT | $2.56 | — |
| VA | $2.56 | — |
| VI | $2.56 | — |
| VT | $2.56 | — |
| WA | $2.56 | — |
| WI | $2.56 | — |
| WV | $2.56 | — |
| WY | $2.56 | — |
Amounts are the Medicare DMEPOS fee-schedule allowables effective April 2026.
Medicare typically pays 80% of the allowable after the Part B deductible; the patient owes 20%.
A 2% sequestration reduction applies to the Medicare share. Former competitive-bidding-area
adjustments and non-continental rates can differ — verify with your DME MAC.
Common denial codes to watch
Related A-codes
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