Urological Supply Coverage and Prescriptions Under Medicare Guidelines


A spinal cord injury / disorder (SCI/D) disrupts messages traveling to or from the brain and can alter the urinary process. When this happens, the bladder cannot tell the brain that it is full, and the brain cannot tell the bladder sphincter to open so that urine can be released. This is referred to as a neurogenic bladder.

Frequently Asked Questions
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    I require the use of a catheter for bladder management. Do I qualify?

    • I have a neurogenic bladder that does not allow me to fully empty my bladder
    • The catheter and associated supplies are reasonable and necessary for the treatment of my illness or injury

    What type of catheter is appropriate when I have a neurogenic bladder with urinary retention?

    To qualify for a specific catheter or kit, you must have all the corresponding Xs in the column.

    *When using a sterile kit, the technique used is a sterile catheterization technique. Otherwise a clean intermittent catheterization technique is used.

    **False passages could make it difficult to place a catheter. Therefore, before using a coude tip catheter, ensure that there are no false passages. Consider asking your prescriber or urologist for further evaluation, which may include a cystoscopy.

    ***The only double balloon indwelling catheter on the market right now is the Duette catheter.

    What must be included in the prescription?

    • Patient name
    • Date of birth (DOB)
    • RX effective date
    • HCPF (Healthcare Policy and Finance) code with description of product being prescribed
      • These can be found in the link at the end of this document
    • Diagnosis of Urinary retention
      • Neurogenic bladder is not an acceptable diagnosis
      • “Prevention” or “preventative” should not be included in prescription
    • Quantity
    • Printed prescriber name
    • Prescriber signature
    • Date of signature
    • NPI number

    What documentation does my prescriber need to provide?

    • Progress Note
      • Requires face-to-face or virtual appointment
      • Must be dated and signed prior to the prescription date
      • Must include the following:
        • Diagnosis of Urinary retention that is permanent or expected to last a minimum of 3 months if using indwelling or intermittent catheters
        • Treatment Plan; for example:
          • Intermittent catheterization
          • Indwelling catheter
        • Frequency of Treatment Plan; for example:
          • Will require 6 single use catheters a day; or
          • Will require 1 indwelling catheter per month
        • “Prevention” or “preventative” should not be included in prescription or Progress Note

    I am unable to pass a straight catheter. What options are available to address this issue?

    • Coude tip catheter
      • Documentation must note that a straight catheter has been tried but could not be passed. For example: The anatomy is such that a straight catheter cannot safely pass and coude tip is required
      • False passages can make it difficult to pass a catheter. Therefore, before using a coude tip catheter, ensure that there are no false passages. Consider asking your prescriber or urologist for further evaluation, which may include a cystoscopy.

    I have recurring urinary tract infections. What options are available to address this issue?

    • In all cases, Medicare will not approve the following specialty catheters until you have been diagnosed with 2 separate urinary tract infections during a 12 month period while using a non-specialty catheter
    • Types of catheters available to you in this case:
      • Infection control indwelling catheters
      • Double balloon indwelling catheters
      • Closed system intermittent catheters
      • Sterile intermittent catheter kits which will only be approved if you meet one of the following criteria:
        • Your spinal cord injury is T3 or above
        • You reside in a nursing facility
        • You are immunosuppressed; for example (not all-inclusive)
          • I am on a regimen of immunosuppressive drugs post-transplant
          • I am on cancer chemotherapy
          • I have AIDS
          • I have a drug-induced state such as chronic oral corticosteroid use
        • You have radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization,
        • You are a female with SCI with a neurogenic bladder and who is pregnant. Note: coverage is only provided during the pregnancy

    I have an intolerance or allergy to standard catheter material. What options are available to address this issue?

    • Silicone or silicone coated catheter
      • Documentation must note that you have a demonstrated intolerance to non-specialty catheters due to allergy for silicone catheter to be covered

    I have severe bladder inflammation or pain related to my indwelling catheter. What options are available to address this issue?

    • Double balloon catheter

    I have recurring encrustation of my catheter. What options are available to address this issue?

    • You may quality for more than one indwelling catheter change per month
    • You may quality for intermittent irrigation

    How can I ensure I receive the correct supplies without substitutions?

    • Be sure the prescription is specific. For example: 24fr lubricious catheter with 5cc balloon rather than 24fr catheter.
    • Prescription may state “dispense as written/do not substitute” Be aware that if the item being ordered does not meet medical necessity guidelines, the supplier will not ship the items.  Also, if the item ordered falls outside of the reimbursement allowed by a private insurer, the supplier will likely not take the order. This should not be an issue with Medicare coverage

    I have insurance other than Medicare? How does this change things?

    • In most cases, private insurance will require the same documentation that Medicare requires


    Taken from:     Local Coverage Determination (LCD): Urological Supplies (L33803)



    Resource Sheet on Urological Supply Coverage and Prescriptions Under Medicare Guidelines was developed by Julia Koeppe, RN, BSN and Christina Draganich, DO, as well as the CRT subcommittee of the ASCIP Advocacy Committee.


    This information is intended for rehabilitation professionals and may be shared with consumers with SCI/D. This resource sheet is not meant to replace the advice from a medical / rehabilitation professional. Medical / rehabilitation professionals are encouraged to discuss this material with consumers in the context of their overall medical rehabilitation care.

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