Incontinence Supplies

Transcription

1 Incontinence Supplies Policy Number: Original Effective Date: MM /01/2015 Lines of Business: Current Effective Date: QUEST Integration 09/28/2018 Section: Other/Miscellaneous Place(s) of Service: Home I. Description Urinary incontinence is defined as the involuntary loss of urine and fecal incontinence is defined as the involuntary loss of feces. Incontinence is a symptom associated with a broad range of medical conditions, including neurological diseases, injuries to the pelvic region or spinal cord, congenital anomalies, infections, and degenerative changes associated with aging. For the purposes of this policy, incontinence supplies are defined as diaper or brief-like garments and underpads used to contain urinary or fecal incontinence and they may be either disposable or reusable/washable. II. Criteria/Guidelines A. Incontinence supplies for urinary incontinence are covered (subject to Limitations and Administrative Guidelines) when criteria 1 to 3 or criterion 4 are/is met: 1. A focused medical history and targeted physical examination have been conducted to evaluate urinary incontinence and to detect factors contributing to incontinence that, if treated, could improve or eliminate the patient s incontinence. Such factors include, but are not limited to: a. Urinary tract infection; b. Atrophic urethritis/vaginitis; c. Medication, e.g., diuretics, drugs that stimulate or block the sympathetic nervous system, or psychoactive medications; d. Medical conditions, e.g., delirium, psychosis, fecal impaction, diabetes, congestive heart failure, neurological diseases that affect motor skills/mobility; e. Environmental conditions, e.g., lack of access to a toilet, restraints, restrictive clothing, or excessive beverage intake; and f. Social circumstances that prevent personal hygiene, e.g., homelessness or inconsistent caregiver support for toileting. 2. Treatable factors contributing to urinary incontinence have been addressed.

2 Incontinence Supplies 2 3. Applicable treatments including lifestyle interventions, behavioral techniques (bladder training, pelvic muscle exercises), pharmacologic therapy, and/or surgical intervention to manage incontinence have been: a. Ineffective or only partially effective; b. Contraindicated; or c. Determined to be inappropriate for the patient. or 4. The patient has long-standing incontinence due to a clearly identified etiology, e.g., advanced dementia, neurological disease. B. Specialty briefs (for example, pull-up-style diapers) are covered when all of the following criteria are met: 1. Criteria II.A.1 to 3 or 4 are met; 2. The patient is not confined to bed. C. Incontinence supplies for fecal incontinence are covered (subject to Limitations and Administrative Guidelines) when criteria 1 to 3 or criterion 4 are/is met: 1. A focused medical history and targeted physical examination have been conducted to evaluate fecal incontinence and to detect factors contributing to incontinence that, if treated, could improve or eliminate the patient s incontinence; 2. Treatable factors contributing to fecal incontinence have been addressed; and 3. Applicable medical or surgical alternatives to correct or control fecal incontinence have been: a. Ineffective or only partially effective; b. Contraindicated; or c. Determined to be inappropriate for the patient. 4. The patient has a long-standing history of incontinence due to a clearly identified etiology, e.g., advanced dementia, neurological disease. III. Limitations A. Incontinence supplies are not covered for members under the age of 3. B. Incontinence supplies are not covered for members without comorbid medical and/or neurodevelopmental conditions that are identified to be the cause of secondary incontinence. C. If approved, incontinence supplies will be covered up to 200 diapers per month and 50 disposable underpads per month or four reusable underpads per month. D. Gloves are covered if they are for the use of the family caregivers of adult and older children. Gloves are not covered for employed or contracted caregivers, as they must supply their own. If approved, gloves will be covered up to 100 per month. E. Some incontinence supplies are considered personal care items and will not be covered. Personal care items include, but are not limited to: wipes, liners, shields, pads, and guards. F. In general, incontinence supplies are not covered for patients using a permanent or temporary device, such as a catheter, to manage incontinence.

3 Incontinence Supplies 3 IV. Administrative Guidelines A. Incontinence supplies require precertification. Requests for precertification for incontinence supplies must be accompanied by clinical documentation from the requesting physician and/or Service Coordinator supporting that the above criteria are met. To precertify, complete HMSA s Precertification Request form and fax or mail the form, or use iexchange, with the primary diagnosis name and ICD-9-CM code specific to the type of incontinence for which the item is required. B. Precertification is required for quantities greater than the stated limits. Justification for these increased quantities must be provided. C. Covered codes: T4521 T4522 T4523 T4524 T4525 T4526 T4527 T4528 T4529 T4530 T4531 T4532 T4533 T4534 T4536 T4537 T4539 T4540 T4541 T4542 T4543 T4544 HCPCS Description Adult sized disposable incontinence product, brief/diaper, small, Adult sized disposable incontinence product, brief/diaper, medium, Adult sized disposable incontinence product, brief/diaper, large, Adult sized disposable incontinence product, brief/diaper, extra large, small, medium, large, extra large, Pediatric sized disposable incontinence product, brief/diaper, small/medium, Pediatric sized disposable incontinence product, brief/diaper, large, Pediatric sized disposable incontinence protective underwear/pull-on, small/medium, Pediatric sized disposable incontinence protective underwear/pull-on, large, Youth sized disposable incontinence product, brief/diaper, Youth sized disposable incontinence product, protective underwear/pull-on, Reusable Incontinence product, protective underwear/pull-on, any size, Reusable Incontinence product, protective underpad, bed size, Reusable Incontinence product, diaper/brief, any size, Reusable Incontinence product, protective underpad, chair size, Incontinence product, disposable underpad, large, Incontinence product, disposable underpad, small, Adult sized disposable incontinence product, protective brief/diaper, above extra large,

4 Incontinence Supplies 4 above extra large, A4927 Gloves, nonsterile, per 100 ICD-10-CM Description F98.0 Enuresis not due to a substance or known physiological condition; enuresis (primary) (secondary) of nonorganic origin; functional enuresis; psychogenic enuresis; urinary incontinence of nonorganic origin F98.1 Encopresis not due to a substance or known physiological condition; functional encopresis; incontinence of feces of nonorganic origin; psychogenic encopresis N39.3 Stress incontinence (female) (male) N39.41 Urge incontinence N39.42 Incontinence without sensory awareness N39.43 Post-void dribbling N39.44 Nocturnal enuresis N39.45 Continuous leakage N39.46 Mixed incontinence N Overflow incontinence N Other specified urinary incontinence; reflex incontinence; total incontinence R15 Fecal incontinence R15.0 Incomplete defecation R15.1 Fecal smearing R15.2 Fecal urgency R15.9 Full incontinence of feces R32 Unspecified urinary incontinence R33.0 Drug induced retention of urine R33.8 Other retention of urine R33.9 Retention of urine, unspecified R39.14 Feeling of incomplete bladder emptying R39.81 Functional urinary incontinence V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

5 Incontinence Supplies 5 This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii s Patients Bill of Rights and Responsibilities Act (Hawaii Revised Statutes 432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA s determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation. VI. References 1. QUEST Hawaii. (2011, February). Medicaid provider manual (Chapter 10). Retrieved from 2. Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD, Shekelle P. Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine. 2014; 161: American Medical Directors Association (AMDA). Urinary Incontinence in the long term care setting. Columbia (MD): American Medical Directors Association (AMDA). 2012: 33 p. 4. Conservative Treatment. In: Lucas MG, Bedretdinova D, Bosch JLHR, Burkhard F, Cruz F, Namibiar AK, de Ridder DJMK, Tubaro A, Pickard RS. Guidelines on urinary incontinence. Arnhem (The Netherlands): European Association of Urology (EAU) Mar: UptoDate. Approach to women with urinary incontinence. Last update September 30, UptoDate. Treatment and prevention of urinary incontinence in women. Last update January 15, UptoDate. Urinary incontinence in men. Last update November 21, 2014.