Catheters and related supplies are used to drain urine from the bladder or promote evacuation of the contents of the colon when a member is unable to completely empty the bladder by voiding or unable to control their bowel movements.
The following providers may provide catheters and related supplies:
Providers must meet any provider criteria, including accreditation, for third-party insurance or for Medicare in order to assist members for whom MHCP is not the primary payer.
MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.
Catheters and related supplies are covered for eligible MHCP recipients unable to completely empty their bladder by voiding or unable to control their bowel movements.
Most members can be served with one indwelling catheter per month. A second catheter may be required if the catheter is accidentally removed, malfunctions, or becomes obstructed or if the person has a medical history that requires the catheter to be replaced more than once per month. One insertion tray is covered per episode of indwelling catheter insertion. An insertion tray is not covered for use with an intermittent catheter. In rare situations, a person may require daily changes of indwelling catheters. Documentation must support the quantity dispensed.
Documentation of medical necessity (such as recurrent encrustation, inability to pass a straight catheter, or sensitivity to latex) is required for a specialty indwelling catheter (A4340) or a silicone catheter (A4312, A4315, A4344).
Most members can be served with 150 - 180 intermittent catheters per month. Up to 300 intermittent catheters without insertion supplies may be required if the person has a medical history that requires more than six episodes of catheterization daily. MHCP does not encourage the reuse of intermittent catheters. Reuse of intermittent catheters can cause infection. Intermittent catheters with sterile insertion supplies are covered if the person has a medical history that requires sterile, rather than clean, catheterization and documentation of medical necessity for sterile catheterization is maintained in the medical supplier’s files. The member’s living arrangement alone does not support the need for sterile catheterization. More than 200 intermittent catheters with insertion supplies per month require authorization. Documentation must support the quantity dispensed. See Authorization subsection for thresholds.
Most members can be served with one to two drainage bags or bottles per month. Additional drainage bags or bottles may be required if the person has a medical history that requires the bag to be replaced more frequently.
Exception: Due to the CMS-required Medically Unlikely Edits (MUEs), A5102 is limited to one per month. Documentation must support the quantity dispensed. See Authorization subsection for thresholds.
Most members who require intermittent irrigation can be served with one irrigation tray or syringe per week. Up to 31 irrigation syringes or trays may be required if the person has a medical condition that requires daily irrigation with a new syringe. Documentation must support the quantity dispensed. Supplies for intermittent irrigation of an indwelling catheter include either an irrigation tray or an irrigation syringe, and sterile water or saline.
Most members who require continuous irrigation can be served with one irrigation tubing set per day for up to two weeks. Up to 31 continuous days may be required if the person has persistent obstructions. Supplies for continuous irrigation include a three-way Foley catheter, irrigation tubing set and sterile water or saline.
Authorization thresholds for urological supplies
Intermittent catheters with insertion supplies
200 units per month
A4357, A4358, A5112
Drainage collection devices
10 units in any combination per month
Anal irrigation is used for fecal incontinence, chronic constipation, or time-consuming bowel management procedures when other conservative bowel management alternatives have been tried and failed.
The member must meet the following criteria:
Most members can be served with one accessory unit per month and two anal irrigation systems per year. One accessory unit is included with code A4459. Up to 22 accessory units (not including the two included with code A4459) and four anal irrigation systems per year may be required if the person requires daily catheter use.
Authorization is required for quantities of intermittent catheters with insertion supplies, or drainage collection systems exceeding limits.
Authorization is always required for code A4459 and accessory units under code A9999. Include documentation of demonstrated failure and length of trial for first-line bowel management methods. For requests of more than 10 accessory units, include documentation supporting the need for daily catheter use
Submit authorization requests and required documentation to the authorization medical review agent.