If you’re asking, “Does Medicare cover urinary catheters?” or trying to understand the specific Medicare guidelines for catheter supplies, you’ve come to the right place. Medicare does offer coverage for various types of urinary catheters, including intermittent catheters, but understanding the requirements and qualifying conditions can be overwhelming. In this guide, we’ll walk you through the different catheter types, Medicare coverage guidelines, and what you need to qualify for advanced catheter products like closed systems.
What Types of Catheters Does Medicare Cover?
Medicare Part B covers intermittent urinary catheters when they are medically necessary and prescribed by your doctor or another qualified healthcare provider to treat permanent urinary retention or incontinence. Medicare may cover up to 200 catheters per month with a valid prescription and proven medical necessity.
Your exact coverage and allowable amounts will depend on your individual needs, diagnosis, prescription, and medical documentation.
Uncoated Intermittent Catheters
- A4351 – Uncoated straight tip catheter
- A4352 – Uncoated coudé tip catheter
Hydrophilic Catheters
- A4295 – Hydrophilic straight tip catheter
- A4296 – Hydrophilic coudé catheter
Closed System Catheter Kits / Sterile Catheters with Insertion Supplies
- A4353 – Non-hydrophilic catheter with insertion supply kit
- A4297 – Hydrophilic closed system catheter kit with insertion supplies
Note: Closed system catheters or catheters with insertion supplies are considered an advanced catheter type, which is only covered in certain circumstances (for example, if you have a spinal cord injury or recurrent urinary tract infections while practicing sterile catheterization). Medicare will require additional documentation before considering coverage of advanced catheters like closed systems.
If you’d like more information direct from CMS, the full Local Coverage Determination (LCD) is available on the CMS website:
- Visit https://www.cms.gov
- Search for “LCD 33803 Urological Supplies”
- Select the result and click View LCD for complete policy details
Does Medicare Cover Closed System Catheters?
While Medicare does cover closed system catheters in specific circumstances, certain qualifications must be met, such as a history of recurrent UTIs or spinal cord injury.
If you are insured with Medicare or a plan that follows Medicare guidelines, practice sterile-use catheterization with sterile lubrication packets and a new straight catheter each time, and you have still experienced at least two UTIs within the last 12 months, you may qualify.
However, there must be proof of these UTIs. Without documentation, you will likely not qualify.
People living with any level of spinal cord injury now also qualify to receive closed system catheters through Medicare.
Talk to our specialists today about your covered options by reaching out!
How to Qualify for Closed System Catheters Through Medicare
To qualify for advanced catheters like closed system catheters, you’ll need specific documentation and proof that you’ve experienced recurrent urinary tract infections. Here’s a simple step-by-step guide to help you:
- Visit Your Doctor: If you believe you have a UTI, visit your doctor and provide a urine specimen for a formal culture test.
- Obtain Documentation: Your urine culture must show greater than 10,000 CFU (colony-forming units) of bacteria to qualify as proof of a UTI. Additionally, your doctor should document any symptoms that correspond with the UTI, such as fever, increased urgency, or muscle spasms.
- Sterile-Use Proof: Your doctor must also document that you’re practicing sterile-use catheterization by using a new catheter and sterile lubrication packet each time you cath.
If you have met these requirements, you may be eligible to receive coverage for closed system catheters through Medicare.
What Documentation Do I Need to Get Advanced Catheters?
So you’ve been getting urinary tract infections while practicing sterile use catheterization. What now? You’ll need proof in the form of documentation in the doctor’s notes.
When you get a urinary tract infection, be sure to visit your doctor’s office. You’ll need to provide a urine specimen culture so your healthcare provider can determine and document whether it is a UTI. In addition, Medicare requires proof of any concurrent (corresponding) symptoms that go along with your UTI. Let’s go over the urine culture and concurrent symptoms.
Urine Cultures for a UTI
First, as mentioned above, visit the doctor if you suspect you have a urinary tract infection. You will need to provide them with a urine specimen so that they can perform a formal culture test to determine if it is indeed a UTI.
If it’s a positive culture report, documentation must show that the urine culture has greater than 10,000 colony-forming units (CFU), indicating that bacteria are present and growing at high colony counts. This counts as positive proof of a urinary tract infection.
Concurrent UTI Symptoms
In addition, your doctor’s office should document any symptoms you’re experiencing at the same time your urine culture is taken.
Inform your doctor if you experience any of the following qualifying concurrent UTI symptoms.
- A fever greater than 100.4ºF or 38ºC
- A change in urgency, increased frequency of catheterization, or incontinence
- Increased muscle spasms
- Systemic leukocytosis, which is an abnormal increase in the number of circulating white blood cells in the complete blood count (CBC)
- Autonomic dysreflexia: sweating, blood pressure elevation, abnormally slow heart rate
- Prostatitis: acute or chronic inflammation of the prostate gland
- Epididymitis: discomfort or pain of the epididymis
- Orchitis: inflammation of one or both of the testes, characterized by swelling and pain
What Might Make You Ineligible for Advanced Catheter Coverage Through Medicare?
To qualify for advanced catheters through your Medicare plan, you must have been practicing sterile use during the times your doctor’s office documented your urinary tract infections. Remember to use one sterile straight catheter (A4351) and one sterile lubrication packet each time you self-catheterize.
The following practices may make you ineligible for advanced catheters through Medicare:
- Not practicing sterile-use catheterization (using a new catheter and a new lubrication packet each time you catheterize)
- Using lubrication packets more than once (not considered sterile use)
- Using a tube of catheter lubricant instead of a new sterile lubrication packet each time
Get Started with Navigating Your Medicare’s Catheter Medicare
If you’re seeking a reliable provider of intermittent catheters, look no further than 180 Medical. We have specialized in intermittent catheters for over twenty years. We have years of experience helping people of all ages, from all stages of life, find the right catheter type for their needs. Additionally, we can verify your insurance plan to determine your coverage for catheters.
Contact our friendly specialists to get started!
Disclaimer: This post provides a general understanding of current Medicare guidelines for coverage of catheters. This is not medical advice. Please consult with your prescribing healthcare professional for medical advice.
