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CurrentAetnaPolicy 0533

Urological Supplies

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Coverage and medical necessity criteria for urinary catheters, external urinary collection devices, related supplies, and selected devices (e.g., inFlow) for Aetna members.

Policy Summary

PayerAetna

PolicyUrological Supplies

Policy CodePolicy 0533

Change TypeNo material change

Effective DateAug 21, 2001

Last ReviewFeb 19, 2024

Next Review DateJun 13, 2024

Key ActionFor continued inFlow coverage beyond 3 months, obtain an in-person re-evaluation (day 31–91) documenting symptom improvement and adherence.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/moroutine indwelling catheter allowance

35/momaximum male external catheters

1/29dinFlow frequency

<=2wcontinuous irrigation limit

16oz/moappliance cleaner max

~50+codes listed

Coverage and Medical Necessity Criteria

General medical necessity

Covered when ALL of the following are met

General prosthetic coverage: Urinary catheters and external urinary collection devices are medically necessary prosthetics for members with permanent urinary incontinence or permanent urinary retention.

Permanent urinary retention = not expected to be corrected within 3 months

Indwelling catheter coverage

Indwelling catheter routine and non-routine supply coverage

Routine indwelling catheter maintenance: One catheter per month is medically necessary for routine catheter maintenance.1 per month

Non-routine catheter change reasons:

Policy Summary

PayerAetna

PolicyUrological Supplies

Policy CodePolicy 0533

Change TypeNo material change

Effective DateAug 21, 2001

Last ReviewFeb 19, 2024

Next Review DateJun 13, 2024

Key ActionFor continued inFlow coverage beyond 3 months, obtain an in-person re-evaluation (day 31–91) documenting symptom improvement and adherence.

SourceLink

On This Page

Non-routine catheter changes are medically necessary for: accidental removal; obstruction (encrustation, mucous plug, blood clot); malfunction (e.g., balloon failure, hole); or history of recurrent obstruction or UTI where scheduled changes at intervals of less than once per month prevent acute events.

Specialty catheter types: TuckSpecialty and all-silicone indwelling catheters are medically necessary when the member cannot use a straight Foley with coating (e.g., recurrent encrustation, inability to pass, latex sensitivity). Use of a Coude tip in females is rarely medically necessary.

3-way catheter use: A 3-way indwelling catheter is medically necessary only if continuous catheter irrigation is medically necessary.

Irrigation

Irrigation supplies

Intermittent irrigation: Supplies for intermittent irrigation are medically necessary when used as needed for acute obstruction of the catheter; routine intermittent irrigations are not medically necessary.

Medically necessary supplies include an irrigation tray or syringe and sterile saline or sterile water; routine use is not covered

Continuous irrigation supplies are medically necessary if there is a history of obstruction and patency cannot be maintained by intermittent irrigation or catheter changes; continuous irrigation is temporary and more than 2 weeks is rarely medically necessary.<= 2 weeks typical

Medically necessary supplies include a 3-way Foley, irrigation tubing set, and sterile saline/water; more than one irrigation tubing set per day is not medically necessary

Intermittent catheterization

Intermittent catheterization (CIC)

Sterile CIC indications: Sterile intermittent catheterization is medically necessary when the member requires catheterization and meets at least one of the following: resides in a nursing facility; is immunosuppressed (e.g., AIDS, chronic corticosteroid use, post-transplant immunosuppression, cancer chemotherapy); has radiologically documented vesico-ureteral reflux on CIC; is a pregnant spinal cord–injured female (during pregnancy only); or has distinct recurrent UTIs (two within prior 12 months) while on clean CIC with sterile lubricant.

UTI defined by urine culture >10,000 CFU plus listed signs/symptoms

Sterile CIC supplies per episode: For each episode of medically necessary sterile catheterization, either a catheter plus an individual packet of sterile lubricant or an intermittent catheter kit (catheter, lubricant, gloves, antiseptic, applicators, drape, tray/bag in sterile package) is medically necessary.

An intermittent catheter kit should be used when packaged as a kit; separately provided components do not provide equivalent sterility

External urinary collection devices

External catheters and female external devices

External devices for incontinence: Male external catheters or female external urinary collection devices are medically necessary for members with permanent urinary incontinence when used as an alternative to an indwelling catheter; they are not medically necessary when the member also uses an indwelling catheter.

Adhesive strips/tape used with male external catheters are included in the allowance

Quantity limits: Generally no more than 35 male external catheters are considered medically necessary per month. For female devices, more than one meatal cup per week or more than one pouch per day are not considered medically necessary.<=35 male catheters/month; <=1 meatal cup/week; <=1 pouch/day

Specialty external catheters: Specialty-type male external catheters (e.g., inflating types, faceplate designs) are medically necessary when the clinical situation justifies their need.

PureWick stance: The PureWick urine collection system is considered unproven and not medically necessary for management of urinary incontinence.

inFlow device coverage

inFlow device

inFlow initial coverage: inFlow device is medically necessary as an alternative to intermittent catheterization for members with permanent urinary retention due to impaired detrusor contractility.one device no more often than every 29 days

Device sizing and initial insertion performed by a physician; device replaced every 29 days

inFlow continuation criteria: Continued coverage beyond the first 3 months requires an in-person re-evaluation no sooner than day 31 and no later than day 91 after initiation documenting symptomatic improvement and verified adherence; without this documentation continued use is not medically necessary.re-evaluation between day 31 and day 91

If re-evaluation occurs after day 91 and shows benefit, coverage resumes from date of re-evaluation

Miscellaneous supplies

Appliance cleaner is medically necessary to clean the inside of certain urinary collecting appliances; more than 16 ounces per month is rarely medically necessary.<=16 oz/month

External urethral clamp: One external urethral clamp or compression device is considered medically necessary every 3 months or sooner if the rubber/foam casing deteriorates.1 per 3 months

Tape for securing catheters: Tape used to secure an indwelling catheter is medically necessary; more than 5 yards of 1-inch tape per month is usually not medically necessary.<=5 yards of 1-inch tape/month

Anchoring devices: Adhesive catheter anchoring devices and catheter leg straps for indwelling urethral catheters are considered medically necessary with quantity limits; adhesive anchoring devices are not considered medically necessary to anchor an indwelling urethral catheter when used for that purpose but may be necessary for suprapubic or nephrostomy tubes.<=3 per week adhesive anchoring; <=1 leg strap/month

A catheter/tube anchoring device is considered medically necessary to anchor a covered suprapubic or nephrostomy tube but not to anchor an indwelling urethral catheter

Covered with criteria

Covered when selection criteria are met for devices and supplies

inFlow coverage: inFlow CPT codes (0596T initial, 0597T replacement) and HCPCS (A4341/A4342) are covered for women with permanently impaired detrusor contractility when selection criteria are met; device is physician-sized/inserted initially and replaced every 29 days.29 days

Supported by background evidence and device description; continued coverage requires re-evaluation as specified

Ureteral stents: HCPCS stent codes (C1875, C2617) are covered when used for management of ureteral obstruction or perioperative ureteral protection per clinical indication.

Urological supplies: Multiple HCPCS supply codes (A42xx, A43xx, T45xx, etc.) are listed as covered items contingent on meeting selection/medical necessity criteria and appropriate diagnosis coding; some items (e.g., A9270 irrigation solutions with antibiotics/chemotherapeutic agents) are non-covered.

Claims must meet policy selection criteria and appropriate ICD-10 coding

The policy lists specific supplies that are not covered when billed separately (except when billed by home health suppliers as part of a home health visit). Examples include: adhesive remover (except when used for ostomy supplies), catheter care kits, catheter clamp or plug, creams/salves/lotions/skin barriers, diapers or disposable underpads, drainage bag holders/stands, gauze pads and other dressings (may be covered under other benefits), measuring containers, urinary drainage trays, urinary suspensory without leg bag, and other incontinence products not directly related to a prosthetic catheter or external urinary collection device.

Irrigation solutions intended for use in the urinary tract are addressed separately. The policy permits supplies for intermittent irrigation when needed for acute catheter obstruction, and allows continuous irrigation only when patency cannot be maintained otherwise and typically for no more than 2 weeks. Solutions that contain therapeutic agents such as antibiotics or chemotherapeutic agents, or certain agents (e.g., acetic acid, hydrogen peroxide), are listed as items of concern and may be considered not covered or experimental for some indications.

Irrigation solutions that contain antibiotics and chemotherapeutic agents are specifically identified as non-covered under HCPCS code A9270.

The policy notes the code A5200 for a percutaneous catheter/tube anchoring device described as an adhesive skin attachment with a quantity limit of maximum 3 per week. The code descriptor indicates that this adhesive skin attachment is not medically necessary to anchor an indwelling urethral catheter, although anchoring devices may be appropriate for suprapubic or nephrostomy tubes per other guidance.

Within the excerpted appendix and ancillary material there are no additional explicit exclusions beyond those listed in the policy’s exclusions section.

Routine irrigation of indwelling catheters is not considered medically necessary; irrigation supplies are permitted only for acute obstruction or when clinically indicated. Additionally, leg bags are considered medically necessary for ambulatory or chair/wheelchair-bound members but the use of leg bags for bedridden members is not medically necessary. The policy also specifies that vinyl and latex leg bags should not be used concurrently.

The PureWick female urine collection system is stated as unproven and not medically necessary for management of urinary incontinence.

The HCPCS code A5200 is described as a percutaneous catheter/tube anchoring device, adhesive skin attachment, with a stated limit of maximum 3 per week. The code descriptor includes the notation that it is not medically necessary to anchor an indwelling catheter.

The provided excerpt does not include additional explicit statements labeled 'not medically necessary' beyond those already cited in the exclusions and code descriptors.

Codes, Quantity Limits, and Frequency Guidance

HCPCS Codes listed in policyHCPCS

A4310	Insertion tray without drainage bag and without catheter (accessories only) [maximum 1 per month for indwelling, not medically necessary for CIC] [includes A4332]
A4311	Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.) [maximum 1 per month, not medically necessary for CIC] [includes A4310, A4332, A4338]
A4312	Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone [maximum 1 per month, not medically necessary for CIC] [includes A4310, A4332, A4344]
A4313	Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation [maximum 1 per month, not medically necessary for CIC] [includes A4310, A4332, A4346]
A4314	Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.) [maximum 1 per month, not medically necessary for CIC] [includes A4310, A4311, A4331, A4332, A4338, A4354, A4357]
A4315	Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone [maximum 1 per month, not medically necessary for CIC] [includes A4310, A4312, A4331, A4332, A4344, A4354, A4357]
A4316	Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation [maximum 1 per month, not medically necessary for CIC] [includes A4310, A4313, A4331, A4332, A4346, A4354, A4357]
A4326	Male external catheter with integral collection chamber, any type, each [alternative to indwelling only - for members with permanent incontinence]
A4327	Female external urinary collection device; metal cup, each [alternative to indwelling only - for members with permanent incontinence] [maximum 1 cup per week]
A4328	Female external urinary collection device; pouch, each [alternative to indwelling only - for members with permanent incontinence] [maximum 1 pouch per day]

1–10 of 60

1/6

Urological HCPCS supply codesHCPCS

A4245	Alcohol wipes, per box
A4247	Betadine or iodine swabs/wipes, per box
A4321	Therapeutic agent for urinary catheter irrigation
A4335	Incontinence supply; miscellaneous
A4455	Adhesive remover or solvent, per oz
A4520	Incontinence garment, any type, each
A4554	Disposable underpads, all sizes
A4649	Surgical supply; miscellaneous
A4927	Gloves, non-sterile, per 100
A4930	Gloves, sterile, per pair

1–10 of 33

1/4

inFlow CPT CodesCPTCovered

0596T	Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement.
0597T	Temporary female intraurethral valve-pump; replacement.

inFlow HCPCS CodesHCPCSCovered

A4341	Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each.
A4342	Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each.

Ureteral stent HCPCS codesHCPCSCovered

C1875	Stent, coated/covered, without delivery system
C2617	Stent, non-coronary, temporary, without delivery system

Related CPT procedure codesCPT

34701-34834	Endovascular Repair of Abdominal Aorta and/or Iliac Arteries
45000-45999	Colon and Rectum Surgery
50300-50380	Donor nephrectomy and renal transplant procedures
50540-50547	Pyeloplasty and related renal surgeries
50575	Renal endoscopy through nephrotomy or pyelotomy
50590	Extracorporeal shock wave lithotripsy (ESWL)
50740-50782	Ureteral/renal reconstructive procedures
52005	Cystourethroscopy, with ureteral catheterization
52332-52356	Cystourethroscopy with various ureteroscopy/pyeloscopy treatments
56405-58999	Female Genital System Surgery

ICD-10 codes (selection criteria dependent)ICD-10

N31.0-N31.9	Neuromuscular dysfunction of bladder
N32.81	Overactive bladder [impaired detrusor contractility]
N32.89	Other specified disorders of bladder
N39.3-N39.498	Stress and other specified urinary incontinence
R32	Unspecified urinary incontinence
R33.0-R33.9	Retention of urine
R39.14	Feeling of incomplete bladder emptying
C64.1-C66.9	Malignant neoplasm of kidney/renal pelvis/ureter (selected ranges)
D30.20-D41.22	Benign/neoplasm of ureter and uncertain behavior codes
N13.1-N13.5	Hydronephrosis and ureteral stricture/obstruction codes

1–10 of 12

1/2

Listed supply items (no codes included in excerpt)mixed

No codes listed

inv-26: Male external catheter quantity limit

LimitMale external catheters: maximum 35 per month

ScopeApplies to disposable male external catheters (A4349/A4326) provided as alternative to indwelling catheters for members with permanent incontinence

IncludesAdhesive strips/tape are included in the catheter allowance

inv-27: inFlow device frequency

FrequencyOne inFlow device no more often than every 29 days

CodesCPT 0596T (initial), 0597T (replacement); HCPCS A4341/A4342

IndicationMedically necessary as an alternative to intermittent catheterization for members with permanent urinary retention due to impaired detrusor contractility

inv-28: Continuous irrigation duration

Typical maximum durationContinuous catheter irrigation: typically medically necessary for up to 2 weeks; more than 2 weeks is rarely medically necessary

SuppliesRequires 3-way Foley and irrigation tubing set; A4355 irrigation tubing set maximum 1 per day, up to 2 weeks total

IndicationContinuous irrigation only when history of obstruction and patency cannot be maintained by intermittent irrigation or catheter changes

inv-29: Appliance cleaner limit

LimitAppliance cleaner: maximum 16 ounces per month

PurposeUsed to clean the inside of certain urinary collecting appliances

Medical necessity noteMore than 16 oz/month is rarely considered medically necessary

inv-30: inFlow replacement interval

Replacement intervalinFlow device: replace every 29 days (essentially monthly)

Who replacesReplaced by the patient or caregiver; initial sizing/insertion performed by a physician

CodingReplacement represented by CPT 0597T and HCPCS A4341 (replacement) and A4342 (accessories)

inv-31: Lubricant maximum for CIC

Monthly maximumLubricant for CIC: maximum 8 ounces of non-sterile lubricating gel per month

Sterile vs clean CICSterile CIC uses single sterile lubricant packet per episode (A4332); clean CIC uses non-sterile lubricant (A4402)

Billing guidanceLubricant per oz. code A4402 referenced for CIC lubricant allowance

inv-32: Adhesive skin attachment frequency limit (A5200)

Frequency limitAdhesive skin attachment (A4333/A5200): maximum 3 per week

Clinical noteAdhesive anchoring devices are not considered medically necessary to anchor an indwelling urethral catheter in some contexts

Alternate optionLeg strap anchoring devices are available and have separate replacement limits (see leg strap rules)

inv-33: Expected duration for some diagnoses

ExpectationCertain ICD-10 diagnoses (e.g., N39.3–N39.498, R32, R33.x) are expected to be of 3 months duration or more

UseDiagnosis codes expected to be ≥3 months duration support coverage for urinary collection devices or catheters when selection criteria are met

ExamplesCodes listed include N31.x, N32.81, N39.3–N39.498, R32, R33.x, R39.14

Provider Requirements, Authorization, and Documentation

Prior Authorization

HCPCS codes covered only if policy criteria and utilization limits met

HCPCS and other supply codes in this policy are covered only when the selection and medical necessity criteria in the policy are met; utilization limits and frequency thresholds noted in the code descriptions apply (for example, one indwelling catheter per month for routine maintenance and specified monthly limits for external catheters and supplies).

One indwelling catheter per month is medically necessary for routine maintenance (see code descriptions and policy criteria).
Utilization limits for specific HCPCS codes (e.g., male external catheters, insertion trays, irrigation tubing) are listed in the code table and apply when selection criteria are met.

Prior Authorization

Device-specific codes require meeting selection criteria (prior auth may apply)

Certain device-specific CPT/HCPCS codes (for example, inFlow CPT 0596T/0597T and HCPCS A4341/A4342, and ureteral stent codes C1875/C2617) are covered only when the policy's selection/medical necessity criteria are met; prior authorization may be required per payer procedures.

inFlow: CPT 0596T (initial) and 0597T (replacement); HCPCS A4341/A4342 — coverage contingent on meeting inFlow selection criteria.
Ureteral stents: HCPCS C1875 and C2617 — coverage contingent on clinical indication per policy.

Prior Authorization

No general prior authorization rule stated for listed urological supplies

The policy excerpt does not specify a blanket prior authorization requirement for the listed urological supply HCPCS codes; check payer-specific prior authorization procedures for potential requirements.

No explicit prior authorization rule is stated for general urological supplies within these chunks; device-specific codes (see inFlow, stents) are noted separately.

Note

Use external catheters as alternative to indwelling — do not use together

Male external catheters and female external urinary collection devices are considered medically necessary as alternatives to indwelling catheters for members with permanent urinary incontinence; they are not medically necessary when the member also uses an indwelling catheter.

Male external catheters: generally limited to 35 per month when used as an alternative to indwelling catheters.
Female devices: limits include no more than 1 meatal cup per week or 1 pouch per day; specialty types may be allowed when clinically justified.
External devices must not be billed/used concurrently with an indwelling catheter.

Note

inFlow considered alternative to CIC for women with impaired detrusor contractility

The inFlow device is presented as a covered alternative to intermittent catheterization for women with permanent urinary retention due to impaired detrusor contractility when selection criteria are met.

inFlow is a sterile, single-use intra-urethral valve-pump replaced every 29 days; initial insertion is physician-sized/inserted.
Clinical trial data (Chen et al.) support inFlow as an alternative to CIC for appropriately selected women.

Step Therapy

No step therapy requirements described

The policy does not describe step therapy requirements for inFlow or other urological supplies in the cited excerpts.

Therapeutic pathway notes describe inFlow as an alternative to CIC, but no formal step therapy/required trial sequence is mandated in these chunks.

Documentation Required

inFlow continued-coverage requires in-person re-evaluation (day 31–91)

For continued inFlow coverage beyond the initial 3 months, the treating practitioner must perform and document an in-person re-evaluation between day 31 and day 91 after initiation showing symptom improvement and verified adherence to use.

Re-evaluation must be an in-person encounter documenting that urinary symptoms are improved and the practitioner verifies adherence to use.
If re-evaluation occurs after day 91 and shows benefit, coverage resumes from the date of that re-evaluation.
If required documentation is not present, continued coverage is considered not medically necessary.

Denial Risk

Sterile CIC requests lacking required clinical criteria may be medically reviewed/denied

Requests for sterile intermittent catheterization that do not meet the policy's specified clinical criteria (e.g., nursing facility residence, immunosuppressed status, documented VUR on CIC, pregnant spinal cord–injured female, or recurrent UTIs while on clean CIC) are subject to medical review and may be denied.

Sterile CIC is limited to members meeting at least one listed condition; the policy defines UTI for these criteria (culture >10,000 CFU plus signs/symptoms).
Requests failing to meet criteria are subject to medical review and potential denial.

Documentation Required

Include listed ICD-10 diagnosis codes that meet selection criteria on claims

Use ICD-10 diagnosis codes listed in the policy (for example, N31.x, N32.81, N39.3–N39.498, R32, R33.x, R39.14) on claims when selection criteria are met to support medical necessity for urological supplies.

Codes such as N32.81 (overactive bladder with impaired detrusor contractility) and R33.x (retention of urine) are specifically associated with inFlow and other device coverage when criteria are met.
Ensure the diagnosis code on the claim aligns with the policy's selection criteria for the requested supply or device.

Documentation Required

No other explicit documentation requirements provided in these excerpts

No additional explicit documentation requirements beyond the inFlow re-evaluation and sterile CIC criteria are provided in these excerpts; the policy history and references are listed but do not add other documentation rules.

Providers should follow the inFlow re-evaluation and sterile CIC documentation standards noted elsewhere in the policy; no other specific documentation requirements are stated in these chunks.

Denial Risk

Irrigation solutions with antibiotics/chemotherapeutic agents (A9270) are non‑covered

Irrigation solutions that contain antibiotics or chemotherapeutic agents (HCPCS A9270) are listed as non-covered and may trigger claim denial if billed.

HCPCS A9270 is identified as a non-covered item for irrigation solutions containing antibiotics/chemotherapeutic agents.
Claims for these solutions should not be submitted as covered supplies under this policy.

Denial Risk

Lack of required in-person re-evaluation documentation for inFlow risks denial of continued coverage

Continued coverage of the inFlow device beyond the initial 3 months will be considered not medically necessary if the required in-person re-evaluation documentation (symptom improvement and verified adherence) is not present.

Supplier must stop billing if inFlow usage discontinues; absence of required re-evaluation documentation is a basis for denial of continued supplies.
If re-evaluation after day 91 documents benefit, coverage resumes from the date of that evaluation.

Documentation Required

Document member meets listed clinical criteria to support sterile CIC

Sterile intermittent catheterization documentation must demonstrate the member meets one of the specific clinical indications listed in the policy (e.g., resides in a nursing facility, is immunosuppressed, has radiologically documented vesico-ureteral reflux on CIC, is a pregnant spinal cord–injured female, or has recurrent UTIs on clean CIC).

For UTI-based criteria, documentation should support culture >10,000 CFU and concurrent listed signs/symptoms.
For each episode of medically necessary sterile catheterization, document either catheter plus individual lubricant packet or an intermittent catheter kit.

Denial Risk

Claims may be denied if coverage rules, code limits, or documentation requirements are not met

Claims for urological supplies are subject to the policy's coverage rules and code-specific frequency/quantity limits; however, this excerpt does not list additional specific denial triggers beyond those already noted (e.g., non-covered items like A9270 or missing required documentation).

Verify the requested HCPCS/CPT code aligns with the member’s clinical indication and policy selection criteria before billing.
Adhere to code frequency limits (e.g., insertion trays, catheter monthly allowances, male external catheter monthly maximum) to reduce claim denials.

Background and Context

Urinary catheters and external urinary collection devices are prosthetic supplies used to manage permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined in the policy as retention not expected to be corrected medically or surgically within 3 months. The policy distinguishes indwelling, intermittent (clean and sterile), and external devices, and sets quantity and duration expectations (for example, routine indwelling catheter allowance and limits for continuous irrigation).

Definitions and Terms

inv-49: Permanent urinary retention

DefinitionPermanent urinary retention: retention not expected to be medically or surgically corrected within 3 months

RelevanceCriterion used to determine medical necessity for prosthetic urinary catheters and devices such as inFlow

ContrastDistinguishes permanent retention from temporary or reversible causes when assessing prosthetic coverage

inv-50: External urinary collection devices

DefinitionExternal urinary collection devices include male external catheters and female pouches or meatal cups

ExclusionsThis term does not include diapers or other types of absorptive pads

ExamplesMeatal cup (female) is a plastic cup held around the urethra and connects to a drainage container; pouch attaches with adhesive

inv-51: Sterile intermittent catheterization

DefinitionSterile intermittent catheterization: use of a new sterile packaged catheter and sterile lubricant for each catheterization; may include sterile gloves, drape, and antiseptic peri-urethral cleansing

Supplies per episodeEach medically necessary sterile catheterization may include either a catheter plus individual sterile lubricant packet or an intermittent catheter kit (catheter, lubricant, gloves, antiseptic, applicators, drape, tray or bag)

IndicationsSterile CIC is medically necessary for specified high-risk conditions (e.g., nursing facility resident, immunosuppressed, documented VUR, pregnant spinal cord-injured female, recurrent UTIs while on clean CIC)

inv-52: Clean intermittent catheterization

DefinitionClean intermittent catheterization: use of soap and water for peri-urethral cleansing, a reusable catheter cleansed between episodes, and non-sterile lubricant

Technique noteCatheter insertion trays are of no proven benefit for clean, non-sterile intermittent catheterization

DistinctionClean CIC differs from sterile CIC in supplies and infection-risk-based indications

inv-53: inFlow device

DefinitioninFlow device: a sterile, single-use intra-urethral valve-pump inserted into the female urethra that actively pumps urine on activation

Replacement intervalDevice is replaced every 29 days; initial sizing and insertion performed by a physician

ComponentsSystem includes the inFlow device and the Activator (hand-held remote) used to operate the pump

inv-54: Extension drainage tubing

DefinitionExtension drainage tubing: tubing of any type or length with connector/adaptor for use with urinary leg bag or urostomy pouch

Sale unitSold per each (each connector/adaptor assembly) and included with certain drainage bag allowances

InclusionsIncluded in allowance for insertion trays with drainage bags, bedside drainage bags, vinyl urinary drainage bags, and urinary suspensorys with leg bags

inv-55: Bedside drainage bag

DefinitionBedside drainage bag: day or night bag with or without anti-reflux device and with or without tube

Sale unitSold per each (one bag per unit); usual maximum quantities apply for routine changes

Allowance noteBedside drainage bags are included in insertion tray allowances and A4357 references bedside bag quantities

inv-56: Urinary drainage bag (leg/abdomen)

DefinitionUrinary drainage bag (leg/abdomen): vinyl or latex leg/abdomen bag with or without tube and straps

Sale unitSold per each; separate codes for vinyl (A4358/A5113) and latex (A5112) leg bags—use one type, not both concurrently

Quantity guidanceLeg bag allowances apply to ambulatory or chair/wheelchair-bound members; use for bedridden members is not medically necessary

inv-57: Leg strap

DefinitionLeg strap: replacement straps used to secure a leg/abdomen urinary drainage bag to the limb (latex or foam/fabric)

Replacement optionsAvailable as latex replacement set (A5113) or foam/fabric replacement set (A5114); sold per set

Quantity limitsLeg strap replacement typically allowed 1 per month per set

Policy Dates, References, and Revision History

Policy metadata in the header shows the policy effective date as 08/21/2001, the last review date as 02/19/2024, and the next scheduled review date as 06/13/2024.