Intermittent catheterization is covered when basic coverage criteria are met and the patient or caregiver can perform the procedure. When clean, non-sterile catheterization technique is used; Medicare will cover replacement of intermittent catheters on a weekly basis unless there is documentation of the medical necessity for more frequent replacement. Non-sterile lubricating gel would be covered for use with clean, non-sterile catheterization technique. Eight units of service (8 oz.) would be covered per month. An individual packet of lubrican is not medically necessary for clean, non-sterile intermittent catheterization.
Intermittent catheterization using sterile technique is covered when the patient requires catheterization and the patient meets one of the following criteria (1-5):
- The patient resides in a nursing facility,
- The patient is immunosuppressed, for example (not all-inclusive):
- on a regimen of immunosuppressive drugs post-transplant,
- on cancer chemotherapy,
- has AIDS,
- The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization,
- The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only),
- The patient has had distinct, recurrent urinary tract infections, while on a program of clean intermittent catheterization, twice within the 12-month prior to the initiation of sterile intermittent catheterization.
A patient would be considered to have a urinary tract infection if they have a urine culture with greater than 10,000 colony forming units of a urinary pathogen AND concurrent presence of one or more of the following signs, symptoms or laboratory findings:
- Fever (oral temperature greater than 38º C [100.4º F])
- Systemic leukocytosis
- Change in urinary urgency, frequency, or incontinence
- Appearance of new or increase in autonomic dysreflexia (sweating, bradycardia, blood pressure elevation)
- Physical signs of prostatitis, epididymitis, orchitis
- Increased muscle spasms
- (greater than 5 white blood cells [WBCs] per high-powered field)
Use of a Coude (curved) tip catheter in female patients is rarely medically necessary. When a Coude tip catheter is used (either male or female patients), there must be documentation in the patient's medical record of the medical necessity for that catheter rather than a straight tip catheter. An example would be the inability to catheterize with a straight tip catheter. This documentation must be available upon request. If documentation is requested and does not substantiate medical necessity, payment will be based on the least costly medically appropriate alternative.
EXTERNAL CATHETERS/URINARY COLLECTION DEVICES:
Male external catheters (condom-type) or female external urinary collection devices are covered for patients who have permanent urinary incontinence when used as an alternative to an indwelling catheter.
The utilization of male external catheters generally should not exceed 35 per month. Greater utilization of these devices must be accompanied by documentation of medical necessity.
Male external catheters (condom-type) or female external urinary collection devices will be denied as not medically necessary when ordered for patients who also use an indwelling catheter.
