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 medically necessary catheters under the Durable Medical Equipment (DME) benefit. A prescription and related doctor’s notes are required. The types of urinary catheters typically covered include:
- Straight Intermittent Catheters (A4351): These are the most common type of catheter. They are designed for single use, meaning you discard each one after using it. Medicare typically covers up to 200 straight catheters per month.
- Hydrophilic Catheters (A4353): These catheters feature a hydrophilic coating, which makes insertion easier and more comfortable by reducing friction. Hydrophilic catheters are especially helpful for people who may have discomfort or difficulty inserting a traditional catheter.
- Closed System Catheters (A4353): Closed system catheters are self-contained, pre-lubricated catheter kits with a collection bag specifically designed to help reduce the risk of contamination and urinary tract infections (UTIs).
For more information about these catheter types, or to determine which catheter best fits your needs, our specialists at 180 Medical are here to help.
Does Medicare Cover Closed System Catheters?
While Medicare does cover these advanced catheter products, certain qualifications must be met, such as a history of recurrent UTIs.
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, remember that it’s important to have proof of these UTIs. Without documentation, you will likely not qualify.
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 doctor’s notes.
When you get a urinary tract infection, be sure to visit your doctor’s office. You’ll need to give a urine specimen culture there so your healthcare provider can determine and document if 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, go to the doctor when you feel like you have a urinary tract infection. You will need to be able to provide them with a urine specimen so that they can do 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 CFU (colony-forming units), which is a way to show that the bacteria is 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.
It is important to mention to your doctor if you have one 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?
In order 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
Having this information before going to see your doctor should give you a leg-up in the process.
After all, your health and comfort are important. Advanced catheter products may potentially help reduce urinary tract infections.
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 in helping people of all ages from all journeys of life find the right catheter type for their needs. Also, we can verify your insurance plan to determine your catheter coverage.
Contact our friendly, trained specialists to get started!
Disclaimer: This post provides a general understanding of current Medicare guidelines for coverage of advanced catheter products (A4353). This is not medical advice. Please consult with your prescribing healthcare professional for medical advice.
