Sterile Intermittent Catheter Kits A4353 or more than 200 Intermittent catheters or coude catheters are covered when one of the following is met: patient resides in nursing home; patient is immuno-suppressed; patient has radiologically documented ureteral vesico-uteral reflux; patient is a spinal cord injured pregnant female; or patient has had at least 2 distinct urinary tract infections within a 12 month period while on a sterile intermittent catheterization program.
Intermittent urinary catheter; coude (curved) tip
A4352
200 per month. Additional documentation is always required to justify medical necessity of coude tip. Coude justifications include: urethral strictures or other inability to pass a straight tip catheter.
Intermittent urinary catheter, with insertion supplies
A4353
Not covered unless sterile approved
Condom Catheters
Male external catheter, with or without adhesive, disposable
A4349
35 per month
If approved for sterile technique of intermittent catheterization or skin breakdown history.
Foley Catheters
Indwelling catheter; Foley type, 2-way latex with coating
A4338
1 per month
Non-routine indwelling catheter changes are covered if one of the following are documented: catheter accidentally removed; catheter malfunction; obstruction of catheter; documented history of recurrent obstruction or urinary tract infection proven to be preventable when catheter is changed more than once a month.
Indwelling catheter; Foley type, 2-way all silicone
A4344
1 per month
Insertion tray without drainage bag and without catheter (accessories only)
A4310
1 per month
Insertion tray without drainage bag with indwelling catheter, Foley type, 2-way latex with coating
A4311
1 per month
Insertion tray without drainage bag with indwelling catheter, Foley type, 2-way all silicone
A4312
1 per month
Insertion tray with drainage bag with indwelling catheter, Foley type, 2-way latex with coating
A4314
1 per month
Insertion tray with drainage bag with indwelling catheter, Foley type, 2-way all silicone
A4315
1 per month
Irrigation Supplies
Irrigation tray with bulb or piston syringe, any purpose
A4320
1 as needed for irrigation, not routinely
Irrigation syringe, bulb or piston
A4322
1 as needed for irrigation, not routinely
Collection Devices
Bedside drainage bag, with or without anti-reflux device, with or without tube
A4357
2 per month
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps
A4358
2 per month
Bedside drainage bottle with or without tubing, rigid or expandable
A5102
1 every 3 months
Urinary leg bag; latex
A5112
1 per month
Miscellaneous Items
Lubricant, individual sterile packet, for insertion of urinary catheter
A4332
1 packet per episode of intermittent catherization
Appliance cleaner, incontinence and ostomy appliances, per 16 oz
A5131
1 per month w/A5112 or A5102
Tape, non-waterproof, per 18 square inches
A4450
1 roll with foley catheter only
Tape, waterproof, per 18 square inches
A4452
1 roll with foley catheter only
Extention drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch
A4331
1 per month w/A5112 or A5102
Note: Monthly allowable amounts do not represent a benefit limit. The actual quantity needed by a particular customer may be more or less than the amount listed, depending on the individual customer's medical condition as prescribed by their physician. Customers ordering over the allowable amount must have appropriate medical justification.
