(B)(C) Urination aids.
(1) Indwelling catheters.
(a) Frequency limits imposed on catheter
replacement may be exceeded without prior authorization (PA) for
any of
reasons
including but not limited to the following
reasons
examples:
(i) Accidental removal of a
catheter;
(ii) Malfunction of a
catheter;
(iii) Obstruction of a
catheter by encrustation, mucus plug, or blood clot; or
(iv) A history of recurrent obstruction or
infection, as a precaution against which the prescriber has specified more
frequent changing of the catheter.
(b) Additional documentation of medical
necessity is needed for either of the following items:
(i) A specialty indwelling catheter or
all-silicone catheter used in lieu of a standard coated Foley catheter;
or
(ii) A three-way indwelling
catheter used either alone or with other components.
(c) Payment will not be made for
more than one insertion tray per episode of indwelling catheter
insertion.
(2) Supplies for intermittent irrigation of
indwelling catheters.
(a) Payment may be made
for either an irrigation tray or an irrigation syringe used on an as-needed
basis to clear an obstruction from an indwelling catheter by
irrigation.
(b) Payment may be made
for sterile water or saline solution for irrigation. No additional payment is
made if the irrigation solution contains acetic acid or hydrogen peroxide. No
payment is made for an irrigation solution containing antibiotics or
chemotherapeutic agents.
(c) No
payment is made for supplies used for the irrigation of an indwelling catheter
at predetermined intervals (routine irrigation).
(3) Supplies for continuous irrigation of
indwelling catheters.
(a) Payment may be made
for an irrigation tubing set, as well as for a three-way Foley catheter, if
there is a history of catheter obstruction and catheter patency cannot be
maintained by intermittent irrigation and necessary changing of the catheter.
Payment will not be made for more than one
irrigation tubing set per day.
(b) Payment may be made for sterile water or
saline solution for irrigation. No additional payment is made if the irrigation
solution contains acetic acid or hydrogen peroxide. No payment is made for an
irrigation solution containing antibiotics or chemotherapeutic
agents.
(c) No payment is made for
supplies if continuous irrigation is used as a preventive measure.
(d) Additional documentation is needed to
establish the medical necessity of continuous irrigation used instead of
intermittent irrigation. This documentation must
is to indicate
the rate of administration and the duration of need.
(e) Additional documentation is needed to
establish the medical necessity of continuous irrigation lasting more than two
weeks.
(4) Intermittent
catheters and related supplies.
(a) Payment may be made for a
sterile intermittent catheter and related supplies (or a catheter kit) only if
at least one of the following additional criteria is met:
(i) The individual is
immunosuppressed;
(ii) The individual has neurogenic
bladder dysfunction because of a spinal cord injury or defect and is currently
pregnant;
(iii) The individual currently
performs intermittent catheterization but has documented vesicoureteral reflux;
or
(iv) The individual currently
performs sterile intermittent catheterization and had at least two distinct
urinary tract infections in the year before starting sterile intermittent
catheterization.
(a)
Payment may be made for a sterile intermittent catheter
and related supplies (or a catheter kit) rather than a clean intermittent
catheter and related supplies if sterile catheterization is medically
necessary. Sterile intermittent catheterization is presumed to be medically
necessary if the individual experiences any of the following conditions:
(i)
Immunosuppression, without regard to cause;
(ii)
Both neurogenic
bladder dysfunction and pregnancy;
(iii)
Documented
vesicoureteral reflux; or
(iv)
At least two
distinct urinary tract infections within the preceding year.
(b) Payment will not be made for
more than one kit containing an intermittent catheter with insertion supplies
per episode of intermittent catheterization.
(c)
(b) Additional documentation is needed to establish
the medical necessity of a coudé catheter used instead of a straight catheter.
The use of a coudé catheter by a female is rarely
necessary.
(5) External
urinary collection devices.
(a) Payment may be
made for a medically necessary external urinary collection device (e.g., a
condom-style catheter for a male, a meatal cup or a pouch for a female) as an
alternative to an indwelling catheter for an individual who has permanent
urinary incontinence.
(b) Payment
will not be made for the concurrent dispensing of both an external urinary
collection device and an indwelling catheter.
(c) Additional documentation is needed to
establish the medical necessity of a specialty external urinary collection
device (e.g., an inflatable condom-style catheter, a pouch with a faceplate).
(d) Payment will not be made for
more than one meatal cup per week or one pouch per day.
(6) Urinary drainage
systems.
(a) Payment may be made for the
routine changing of a urinary drainage system.
(b) Payment will not be made for the
concurrent dispensing of a vinyl and a latex bag.
(c) Payment will not be made for leg bags for
individuals who do not leave their bed.
(d) Payment will not be made for
more than one type of leg bag or leg bag strap within a twelve-month
period.
(7) Miscellaneous supplies.
(a) Payment may be made for cleaner for a
urinary collection device or drainage system only if the individual is using
the collection device or drainage system.
(b) Payment may be made for a medically
necessary adhesive anchoring device used to secure an indwelling urethral
catheter, a suprapubic catheter, or a nephrostomy tube.
(c) Payment may be made for a medically
necessary leg strap used to secure an indwelling urethral catheter.
