Sterile Intermittent Catheterization
Guidelines "Quantity of catheters covered is based on physician
orders.'
Intermittent catheterization using
sterile technique is covered when the patient requires catheterization
and the patient meets one of the following criteria:
The patient resides in a nursing facility
The patient is immunosuppressed
On a regimen of immunosuppressive drugs
post-transplant
On cancer chemotherapy
Has AIDS
Has a drug-induced state such as chronic
oral corticosteroid use
The patient has radiologically documented
vesico-uteteral reflux while on a program of intermittent
cauterization
The patient is a spinal-cord injured female
with neurogenic bladder who is pregnant (for duration of
pregnancy only)
The patient has had urinary tract infections,
while on a program of clean intermittent catheterization,
or twice within a year prior to the initiation of sterile
intermittent catheterization
A patient would be considered to have a urinary
tract infection if they have a urine culture with greater
than 10,000 colony forming units of a urinary pathogen and
concurrent presence of one or more of the following signs,
symptoms, or laboratory findings:
Fever
Systemic leukocytosis
Change in urinary urgency, frequency, or
incontinence
Appearance of autonomic dysreflexia (sweating,
bradycardia, blood pressure elevation)
Physical signs of prostatitis, epididymitis,
orchitis
Increased muscle spasms
Pyuria (greater than 5 white blood cells
per high powered field)
The medical necessity for use of sterile intermittent
catheterization for reasons other than the criteria listed
above may be presented for individual consideration.
