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Advanced Catheter Requirements With Medicare

Advanced Catheter Requirements With Medicare

Are you curious about the advanced catheter requirements with Medicare insurance coverage? Wondering if you could qualify for advanced products like closed systems through your Medicare plan? Let’s go over some of the info you should know about this topic.

First, let me introduce myself. My name is Bill. Over 30 years ago, I was involved in a motocross accident. Due to that accident, I sustained a spinal cord injury that made me a quadriplegic. You can learn more about my story of recovery here.

bill fullerton motocross racing before his injury

Over the years since then, I’ve mentored others after their spinal cord injuries. I am happiest when I am using my experience to help others.

UTI Risk with Using Catheters

One thing that I often talk to people about is recurring urinary tract infections (UTIs), which are also known as UTIs.

It’s an unfortunate truth that self-catheterization may carry a risk of getting UTIs. While this is more common in people who reuse their catheters, UTIs can still happen sometimes to people who are practicing sterile use catheterization.

One upside to this is that you may have options to use advanced catheter products, such as closed system catheters. Closed system catheters, in particular, are self-contained catheters that have unique features specifically designed to help reduce the risk of hand contamination and urinary tract infections.

advanced catheters may help reduce the risk of UTIs

Does Medicare Cover Closed System Catheters?

So, does Medicare cover advanced catheter products like closed system catheters? Unfortunately, at this time, people with Medicare (or an insurance plan following Medicare’s guidelines) may not have closed system catheters as an immediate option.

However, if you continue to get urinary tract infections while practicing sterile-use catheterization, you may have an option to get your Medicare plan to cover closed system catheters.

link to learn more about closed system catheters

What Is Sterile-Use Catheterization?

So what does sterile-use catheterization mean? This means using a catheter and sterile catheter lubrication packet one time and then disposing of it after use without cleaning it or reusing again. In other words, only using a sterile catheter each time you have to cath.

Could I Qualify to Get Closed System Catheters Through Medicare?

It’s possible! 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.

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. There, you’ll need to give a urine specimen culture 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 Catheters Through Medicare Coverage?

In order to qualify for advanced catheters through your Medicare plan, you need to have been practicing sterile use during the times your doctor’s office documented your urinary tract infections. Keep in mind, that means you must be using 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.

Where to Find Catheters Through Medicare

If you’re seeking a reliable provider of intermittent catheters, look no further than 180 Medical. We have specialized in intermittent catheters for nearly 2 decades, and we have years of experience in helping people of all ages from all journeys of life in finding 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!

contact 180 medical

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.

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About the Author
Bill worked for 180 Medical for over 10 years. As a quadriplegic with over 30 years of experience, Bill loves peer mentoring, sharing his first-hand experiences, and helping others who may have questions about life after a spinal cord injury and self-catheterization. He enjoys spending time outdoors as well as watching and attending motocross events.