CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

Urological Supplies

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This policy governs Medicaid coverage and limitations for urological supplies, including catheters and external urinary collection devices, when members have permanent urinary incontinence or permanent urinary retention and applicable coverage criteria are met.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyUrological Supplies

Policy CodePolicy N/A

Change TypeAdministrative revisionno material clinical or coverage change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the required prescription, medical-necessity documentation, and physician or practitioner examination documentation within 90 days before the service authorization start date.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NoService authorization required

2Qualifying permanent conditions

1/monthRoutine catheter allowance

90 days

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CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

Urological Supplies

Customize your policy alerts

Sign up for all North Dakota Department of Health & Human Services policy alerts

Know when North Dakota Department of Health & Human Services releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyUrological Supplies

Policy CodePolicy N/A

Change TypeAdministrative revisionno material clinical or coverage change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the required prescription, medical-necessity documentation, and physician or practitioner examination documentation within 90 days before the service authorization start date.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NoService authorization required

2Qualifying permanent conditions

1/monthRoutine catheter allowance

90 days

A4358 or A5112Covered leg bag codes

Coverage Criteria

Initial coverage criteria

Coverage is allowed when all applicable requirements are met:

Urological supplies coverage

Qualifying condition
- Permanent urinary incontinence.
- Permanent urinary retention.
Eligible device: The catheter or external urinary collection device meets the applicable coverage criteria.
Supplies necessary for effective use are covered only when the associated device meets coverage criteria.

Catheter change criteria

Catheter replacement is covered under either of the following circumstances:

Catheter change circumstances

Routine maintenance: The catheter is provided for routine catheter maintenance.No more than one catheter per month
More than one catheter per month is not covered for routine catheter maintenance.
Non-routine change: The catheter change is non-routine and documentation substantiates medical necessity.
Examples include accidental removal, malfunction, or obstruction.

Leg bag criteria

Leg bags are covered when all applicable requirements are met:

Leg bag eligibility

Member mobility status: The member is ambulatory, chair-bound, or wheelchair-bound.
Covered leg bag option: One applicable leg bag option is used: A4358 or A5112.
The use of both leg bag options together is not medically necessary.

Use of both leg bag options together is not medically necessary.

The leg bag options are A4358 and A5112. Both options should not be used together because their simultaneous use is not medically necessary.

Covered Supplies and Quantity Limits

Covered leg bag codesHCPCSCovered

A4358	Leg bag
A5112	Leg bag

Routine Catheter Maintenance

ServiceRoutine catheter maintenance

Quantity allowanceNo more than one catheter per month

Provider Actions and Denial Risks

Note

No Service Authorization Required

Service authorization is not required for urological supplies.

Documentation Required

Urological Supplies Documentation

Submit the documentation required to establish coverage for urological supplies. The physician or practitioner examination must occur within 90 days of the service authorization start date.

A prescription from a prescribing practitioner.
Medical documentation supporting the need.
Physician/practitioner examination documentation within 90 days of the service authorization start date.

Documentation Required

Document Non-Routine Catheter Changes

Policy Background

This policy addresses urological supplies for members with permanent urinary incontinence or permanent urinary retention. Covered supplies include catheters and external urinary collection devices, when the related device meets the applicable coverage criteria.

Medical Necessity

Medical necessity for urological supplies

Equipment and related supplies are covered when all applicable criteria are met:

Qualifying urinary condition
- Permanent urinary incontinence.
- Permanent urinary retention.
Covered device: The catheter or external urinary collection device meets the applicable coverage criteria.

Replacement Allowances

Routine Catheter Replacement

ServiceRoutine catheter replacement

Replacement limitNo more than one catheter per month

Non-routine Catheter Replacement

ServiceNon-routine catheter replacement

CoverageCovered as medically necessary when documentation substantiates the need

ExamplesAccidental removal, malfunction, or obstruction

Required Documentation

Documentation Required

Provide required documentation

Documentation must include a prescription from a prescribing practitioner, medical documentation supporting the need, and a physician or practitioner examination within 90 days of the service authorization start date.

Documentation Required

Document the reason for a non-routine change

For a non-routine catheter change, documentation must substantiate medical necessity and identify the specific reason for the change, such as accidental removal, malfunction, or obstruction.

Non-Covered Items and Uses

The following are not covered: more than one catheter per month for routine catheter maintenance and simultaneous use of both leg bag options, A4358 and A5112.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyUrological Supplies

Policy CodePolicy N/A

Change TypeAdministrative revisionno material clinical or coverage change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the required prescription, medical-necessity documentation, and physician or practitioner examination documentation within 90 days before the service authorization start date.

SourceLink

On This Page

Non-routine catheter changes are covered only when documentation substantiates medical necessity and identifies the circumstance supporting the change.

Examples include accidental catheter removal, malfunction, or obstruction.

Denial Risk

Qualifying Condition and Device Required

Coverage is allowed only when permanent urinary incontinence or permanent urinary retention is present and the catheter or external urinary collection device meets coverage criteria. Supplies necessary for effective use are covered only when the related catheter or device qualifies.

Coverage condition: permanent urinary incontinence or permanent urinary retention.
Deny coverage when neither qualifying permanent condition is present or when the catheter or external urinary collection device does not meet coverage criteria.

Billing Rule

Catheter Quantity and Replacement Limits

No more than one catheter per month is covered for routine catheter maintenance. Non-routine replacements or changes require documentation substantiating medical necessity and the specific circumstance supporting the change; review the Procedure Code Look-Up Tool for code quantity allowables.

Routine maintenance limit: one catheter per month.
Document non-routine circumstances such as accidental removal, malfunction, or obstruction.
Additional or replacement catheters are at risk of denial when quantity limits or medical-necessity documentation are not supported.

Denial Risk

Avoid Duplicate Leg Bag Use

Leg bags A4358 and A5112 are indicated for members who are ambulatory or chair- or wheelchair-bound. Using both leg bag options is not medically necessary and is subject to denial.

Applicable leg bag codes: A4358 or A5112.
Do not use both leg bag options for the same member when one is sufficient.

Denial Risk

Required Documentation Must Be Present

Claims are at risk of denial when the required prescription, medical-necessity documentation, or examination documentation is absent. Ensure all documentation is submitted to support the requested urological supplies.

Prescription from a prescribing practitioner.
Medical documentation supporting the need.
Physician/practitioner examination within 90 days of the service authorization start date.