The use of leg bags for bedridden members is not considered medically necessary.Įither a vinyl leg bag or a latex leg bag is considered medically necessary the use of both is not considered medically necessary. Leg bags are considered medically necessary for members who are ambulatory or are chair- or wheelchair-bound.
Urinary leg bag vinyl, with or without tube, eachīedside drainage bottle with or without tubing, rigid or expandable, each Insertion tray with drainage bag but without catheterīedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each Insertion tray with drainage bag with indwelling catheter, Foley-type, 3-way, for continuous irrigation Insertion tray with drainage bag with indwelling catheter, Foley-type, 2-way, all silicone Insertion tray with drainage bag with indwelling catheter, Foley-type, 2-way, latex with coating Table: Usual Maximum Medically Necessary Quantity of Supplies Description Additional supplies for non-routine changes are considered medically necessary only under exceptional circumstances (e.g., for obstruction, sludging, clotting of blood, or chronic, recurrent urinary tract infections). The following table indicates the quantity of supplies that are considered medically necessary for routine changes of the urinary drainage collection system.
Catheter insertion trays are of no proven benefit for clean, non-sterile intermittent catheterization.Ĭatheter insertion trays that contain component parts of the urinary collection system, (e.g., drainage bags and tubing) are inclusive sets and additional component parts are considered medically necessary only per the stated criteria in each section of this policy. One intermittent catheter with insertion supplies is considered medically necessary per episode of medically necessary sterile intermittent catheterization (see below). One insertion tray is considered medically necessary per episode of indwelling catheter insertion. For example, use of a Coude (curved) tip indwelling catheter in female members is rarely medically necessary.Ī 3-way indwelling catheter either alone or with other components is considered medically necessary only if continuous catheter irrigation is medically necessary. Specialty indwelling catheters and all silicone catheters are considered medically necessary where the member is unable to use a straight Foley type catheter with coating (such as recurrent encrustation, inability to pass a straight catheter, or sensitivity to latex). Member has history of recurrent obstruction or urinary tract infection for which it has been established that an acute event is prevented by a scheduled change at intervals of less than once per month.
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