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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say Coverage Indications, Limitations, and/or Medical Necessity 
 
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be 
reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a 
malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. 
 
The purpose of a Local Coverage Determination (LCD) is to provide information regarding reasonable and 
necessary criteria based on Social Security Act  1862(a)(1)(A) provisions. 
 
In addition to the reasonable and necessary criteria contained in this LCD there are other payment rules, 
which are discussed in the following documents, that must also be met prior to Medicare reimbursement: 
 
    The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under 
the Related Local Coverage Documents section. 
    The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage 
Documents section. 
    Refer to the Supplier Manual for additional information on documentation requirements. 
    Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD. 
 
For the items addressed in this LCD, the reasonable and necessary criteria, based on Social Security Act  
1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical 
necessity. 
 
The statutory coverage criteria for coverage of urological supplies are specified in the related Policy Article. 
 
The medical necessity for use of a greater quantity of supplies than the amounts specified in the policy must be 
well documented in the beneficiary's medical record and must be available upon request. 
 
INDWELLING CATHETERS (A4311, A4312, A4313, A4314, A4315, A4316, A4338, A4340, A4344, and 
A4346) 
 
No more than one catheter per month is covered for routine catheter maintenance. Non-routine catheter changes are covered when documentation substantiates medical necessity, such as for the following indications: 
 
   1. Catheter is accidentally removed (e.g., pulled out by beneficiary) 
   2. Malfunction of catheter (e.g., balloon does not stay inflated, hole in catheter) 
    3. Catheter is obstructed by encrustation, mucous plug, or blood clot 
    4. History of recurrent obstruction or urinary tract infection for which it has been established that an acute 
event is prevented by a scheduled change frequency of more than once per month 
 
A specialty indwelling catheter (A4340) or an all silicone catheter (A4344, A4312, or A4315) is covered when 
the criteria for an indwelling catheter (above) are met and there is documentation in the beneficiary's medical 
record to justify the medical need for that catheter (such as recurrent encrustation, inability to pass a straight 
catheter, or sensitivity to latex(not all-inclusive)). In addition, the particular catheter must be necessary for the 
beneficiary. For example, use of a Coude (curved) tip indwelling catheter (A4340) in a female beneficiary is 
rarely reasonable and necessary. If documentation is requested and does not substantiate medical necessity 
payment for A4340, A4344, A4312, or A4315 will be denied as not reasonable and necessary. A three-way 
indwelling catheter either alone (A4346) or with other components (A4313 or A4316) will be covered only if 
continuous catheter irrigation is reasonable and necessary. (Refer to the section "Continuous Irrigation of 
Indwelling Catheters" for indications for continuous catheter irrigations.) In other situations, A4346, A4313 
and A4316 will be denied as not reasonable and necessary. You can find this information in Medicare's Local 
Coverage Determination (LCD): Urological Supplies (L33803). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.