Incontinence Supplies Policy Number: Original Effective Date: MM.12.020 07/01/2015 Lines of Business: Current Effective Date: QUEST Integration 07/01/2015 Section: Other/Miscellaneous Place(s) of Service: Home I. 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 all of the following criteria are met: 1. The patient is over the age of three years. 2. 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. 3. Treatable factors contributing to urinary incontinence have been addressed.
Incontinence Supplies 2 4. 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. 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 4 are met; 2. The patient is participating in a clinician-designed behavioral toileting program; 3. The patient has the strength, agility, and dexterity to stand up and pull them on themselves; and 4. The patient is not bedridden and is able to ambulate. C. Incontinence supplies for fecal incontinence are covered (subject to Limitations and Administrative Guidelines) when the following criteria are 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. III. Limitations A. If approved, incontinence supplies will be covered up to 200 diapers per month and 50 disposable underpads per month or four reusable underpads at a time. B. 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. C. 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. D. In general, incontinence supplies are not covered for patients using a permanent or temporary device, such as a catheter, to manage incontinence. 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 with the primary diagnosis name and ICD-9-CM code specific to the type of incontinence for which the item is required.
Incontinence Supplies 3 B. Precertification is required for quantities greater than the stated limits. Justification for these increased quantities must be provided. C. Covered codes: HCPCS T4521 Adult sized disposable incontinence product, brief/diaper, small, T4522 Adult sized disposable incontinence product, brief/diaper, medium, T4523 Adult sized disposable incontinence product, brief/diaper, large, T4524 Adult sized disposable incontinence product, brief/diaper, extra large, T4525 small, T4526 medium, T4527 large, T4528 extra large, T4529 Pediatric sized disposable incontinence product, brief/diaper, small/medium, T4530 Pediatric sized disposable incontinence product, brief/diaper, large, T4531 Pediatric sized disposable incontinence protective underwear/pull-on, small/medium, T4532 Pediatric sized disposable incontinence protective underwear/pull-on, large, T4533 Youth sized disposable incontinence product, brief/diaper, T4534 Youth sized disposable incontinence product, protective underwear/pull-on, T4536 Reusable Incontinence product, protective underwear/pull-on, any size, T4537 Reusable Incontinence product, protective underpad, bed size, T4539 Reusable Incontinence product, diaper/brief, any size, T4540 Reusable Incontinence product, protective underpad, chair size, T4541 Incontinence product, disposable underpad, large, T4542 Incontinence product, disposable underpad, small, T4543 Adult sized disposable incontinence product, protective brief/diaper, above extra large, T4544 above extra large, A4927 Gloves, nonsterile, per 100 ICD-9-CM Diagnosis 307.6 Enuresis (primary (secondary) of nonorganic origin 307.7 Encopresis (continuous) (discontinuous) of nonorganic origin
Incontinence Supplies 4 625.6 Stress incontinence, female 787.60 Full incontinence of feces 787.61 Incomplete defecation 787.62 Fecal smearing 787.63 Fecal urgency 788.20 Retention of urine, unspecified 788.21 Incomplete bladder emptying 788.29 Other specified retention of urine 788.30 Urinary incontinence, unspecified 788.31 Urge Incontinence 788.32 Stress incontinence, male 788.33 Mixed incontinence, (male) (female) 788.34 Incontinence without sensory awareness 788.35 Post-void dribbling 788.36 Nocturnal enuresis 788.37 Continuous leakage 788.38 Overflow incontinence 788.39 Other urinary incontinence 788.91 Functional urinary incontinence ICD-10 codes are provided for your information. These will not become effective until 10/01/2015: ICD-10-CM 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 N39.490 Overflow incontinence N39.498 Other specified urinary incontinence; reflex incontinence; total incontinence R15.0 Incomplete defecation R15.1 Fecal smearing R15.2 Fecal urgency R15.9 Full incontinence of feces
Incontinence Supplies 5 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. 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 http://www.medquest.us/pdfs/provider%20manual/pmchp1011.pdf 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: 429-440. 3. 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). 2013 Mar: 27-49. 5. UptoDate. Approach to women with urinary incontinence. Last update September 30, 2014. 6. UptoDate. Treatment and prevention of urinary incontinence in women. Last update January 15, 2015. 7. UptoDate. Urinary incontinence in men. Last update November 21, 2014.