1. Medicare Guidelines for Urological Supplies
   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. Customers ordering over the allowable amount must have appropriate medical justification (i.e. a letter of medical necessity)

2. Some Medicare Coverage Rules that should be noted (Partial Overview):
1. Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months.
2. If the catheter or the external urinary collection device meets the coverage criteria then the related supplies that are necessary for their effective use are also covered. Urological supplies that are used for purposes not related to the covered use of catheters or external urinary collection devices (i.e., drainage and/or collection of urine from the bladder) will be denied as non-covered. Urological supplies billed without the required Documentation will be denied as non-covered.
3. The patient must have a permanent impairment of urination. This does not require a determination that there is no possibility that the patient's condition may improve sometime in the future. If the medical record, including the judgment of the attending physician, indicates the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met. Catheters and related supplies will be denied as non-covered in situations in which it is expected that the condition will be temporary.
4. The use of a urological supply for the treatment of chronic urinary tract infection or other bladder condition in the absence of permanent urinary incontinence or retention is non-covered. Since the patient's urinary system is functioning, the criteria for coverage under the prosthetic benefit provision are not met.
5. The medical necessity for use of a greater quantity of supplies than the amounts specified in the policy must be well documented in the patient's medical record.
1. Quantities exceeding the following, must include documentation supporting the medical necessity for the higher utilization. This information must be filed in the patient's medical record and included with the claim to Medicare.:
1. more than one indwelling catheter per month,
2. more than two bedside drainage bags per month,
3. more than 35 male external catheters per month, etc.),
6. Indwelling Catheters (A4311 - A4316, A4338 - A4346):
1. No more than one (1) catheter per month is covered for routine catheter maintenance. Non-routine catheter changes are covered when documentation substantiates medical necessity.
2. When a specialty indwelling catheter (A4340) or an all silicone catheter (A4344, A4312, or A4315) is used, there must be documentation in the patient's medical record of the medical necessity for that catheter rather than a straight Foley type catheter with coating (such as recurrent encrustation, inability to pass a straight catheter, or sensitivity to latex). In addition, the particular catheter must be necessary for the patient. For example, use of a Coude (curved) tip indwelling catheter (A4340) in female patients is rarely medically necessary. Documentation of medical necessity must be filed in the patient's medical record.
3. A three way indwelling catheter either alone (A4346) or with other components (A4313 or A4316) will be covered only if continuous catheter irrigation is medically necessary.
7. Urinary Drainage Collection System (A4314-A4316, A4354, A4357, A4358, A5102, A5112):
1. Payment will be made for routine changes of the urinary drainage collection system.
8. External Catheters/Urinary Collection Devices
1. Male external catheters (condom-type) or female external urinary collection devices are covered for patients who have permanent urinary incontinence when used as an alternative to an indwelling catheter.
2. The utilization of male external catheters (A4324 or A4325) generally should not exceed 35 per month. Greater utilization of these devices must be accompanied by documentation of medical necessity.
9. Leg bags are indicated for patients who are ambulatory or are chair or wheelchair bound.
10. Irrigation supplies that are used for care of the skin or perineum of incontinent patients are non-covered.
11. For female external urinary collection devices, more than one metal cup (A4327) per week or more than one pouch (A4328) per day will be denied as not medically necessary.

Better living Now, Inc. assumes no responsibility in regards to Medicare coverage and has interpreted Medicare Rules for the benefit and understanding of the patient. For detailed information regarding Medicare coverage please visit their web site at: www.cms.gov. For Coverage Information for Urological Supplies go to: http://www.tricenturion.com/content/dmerc/0602_16_10_Urological_supplies.cfm