Getting Medicare to pay for closed system catheter kits

[Reesa]

Hi,

I have MS and recently switched from private insurance to Medicare. The private insurance covered 180 closed system catheter kits (A4353) a month as my urologist prescribed. But now my durable medical goods provider says my doctor's report does not satisfy the Medicare guidelines to get the closed system -- they believe only the straight catheters (A4352) with lube will be covered.

I'm aware of the Medicare LCD for Urological Supplies (L5080), see excerpt attached. Following this, my doctor stated I am immunosuppressed because of taking Copaxone for MS. But the provider says Copaxone is not an immune-suppressant drug. Copaxone's literature says it's an immunomodulator: the fine print says "because [it] can modify immune functions, concerns exist about its potential to alter naturally occurring immune responses ... there is no logical way to absolutely preclude this possibility."

I would appreciate any advice here. I could go back to using straight caths and wait until I get two infections (it probably won't be long, as past experience has shown). But I have decided to tell the provider to file the claim for the closed system kits and hope that either Medicare approves -- or I win if it has to be appealed.

The Medicare LCD for Urological Supplies (L5080) is not fair, IMO. The main reason I need the closed kit instead of a straight catheter is because of my handicap -- one of my hands is weak and shaky because of the MS, making it impossible for me to stay sanitary without the closed kit. What would be the best way to protest this LCD?

[6 Shooter]

My son is using a Baird closed catheter system and is a C-6 quad 2 yrs 10 months post. He is now on Medicare and Medicare has just begun to pay for the closed catheter system--180 per month. It took 3-4 months working with his previous private insurance company, the catheter distributor, and my son's urologyst (for UTI history records).

Medicare first required a history of urinary track infections and then a recent history of no UTIs using the closed systems. So far, so good.

[SCI-Nurse]

It seems as though you may have already been through some of the hoops that Medicare is trying to put you through. You have a history of uti's when you don't use a closed system and significantly less when you do use it. You need to document this in writing and get your physician to sign it with you. Then make your appeal. Hopefully this will work sooner versus later, so that you don't end up sick in the meantime.

CKF

[Jr Medical]

Reesa,
Did you ever get Medicare to approve the closed system or did you just have to start using the straight catheters?

[SCI-Nurse]

Reesa,
Did you ever get Medicare to approve the closed system or did you just have to start using the straight catheters?

You must be pretty desperate to drum up some business for yourself to pull up 3 year old posts and respond to them like this, esp. since the OP has not visited our site since 2009 and is pretty much guaranteed not to see your response to their question.

(KLD)