Is PureWick Medicare Covered? Your Coverage and Billing Options

Living with urinary incontinence is a problem many of us face, especially those looking for non-invasive options like the PureWick external catheter. The PureWick system has become a go to solution for those who need an easy and comfortable way to manage urinary output. But the question is: Is PureWick Medicare covered? This article will break down Medicare coverage for the PureWick urine collection system, including Medicare billing and HCPCS codes and how different insurance policies apply.

Medicare Coverage for Medical Devices

Medicare 101: A Federal Health Insurance Program

Medicare is a federal health insurance program for people 65 and older. It also covers some younger people with disabilities or end-stage renal disease. Medicare is broken down into several parts but Parts B and Medicare Advantage (Part C) are the most relevant when it comes to coverage for medical devices like the PureWick system.

• Part B covers outpatient care, doctor visits, certain preventive services and Durable Medical Equipment (DME).

• Medicare Advantage (Part C) plans are offered by private insurance companies approved by Medicare and cover all the benefits of Original Medicare and sometimes additional DME benefits.

Coverage Criteria for Urine Collection Systems

To be eligible for Medicare coverage a medical device must meet certain criteria. For urine collection systems like the PureWick external catheter three criteria must be met:

1. Medical Purpose: The device must be used for a medical purpose such as managing urinary incontinence.

2. Durability and Reusability: It must be a durable, reusable piece of equipment that a doctor prescribes for long term use.

3. Defined Medicare Benefit Category: The device must fall under a defined Medicare benefit category, be reasonable and necessary for diagnosis or treatment and meet the applicable Medicare statutory and regulatory requirements.

DMEPOS and Urine Collection Systems

What is DMEPOS?

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) covers a broad range of medical devices including external urinary catheters like the PureWick system. For these devices to be covered they must be used for a medical purpose, be durable and reusable and be prescribed by a doctor.

Coverage Under Medicare Part B

Under Medicare Part B durable medical equipment like the PureWick urine collection system may be covered if used to manage a medical condition like permanent urinary incontinence. But not all DME is automatically covered. Medicare will only cover equipment that meets its coverage criteria including being prescribed by a doctor and used for a medical condition that is recognized by Medicare.

Coverage Under Medicare Advantage Plans

Medicare Advantage plans may offer additional benefits beyond Original Medicare. These plans are offered by private insurance companies approved by Medicare and sometimes include broader DMEPOS coverage. To see if your specific Medicare Advantage plan covers the PureWick urine collection system you would need to:

• Contact Your Plan Provider: Reach out to your Medicare Advantage plan provider to ask if the PureWick urine collection system is covered under your plan.

• Review Plan Documentation: Check your coverage booklets, online resources or member portals provided by your Medicare Advantage plan.

• Consult Healthcare Providers: Get necessary documentation and support from your healthcare provider to establish medical necessity of the device.

Commercial Insurance and Medical Insurance Coverage

Commercial Insurance Options

Beyond Medicare some patients may look into commercial insurance options to cover the cost of the PureWick system. Commercial insurance providers have different criteria for covering DME and urological supplies like the PureWick urine collection system. If you have commercial insurance you should:

• Review Your Policy: See what types of DME are covered under your plan. Some plans may cover devices for urinary incontinence more generously than Medicare.

• Contact Your Insurance Provider: Reach out to your insurance company directly to ask about coverage for the PureWick system including necessary documentation and conditions for coverage.

Medical Insurance

Medical insurance whether Medicare, Medicaid or commercial insurance covers the cost of medical devices. When considering the PureWick system:

• Check for DME Coverage: Make sure your medical insurance covers durable medical equipment and urine collection systems.

• Understand Prosthetic Device Benefits: Some insurance plans cover external catheters under the prosthetic device benefit as defined by the Social Security Act which covers devices that replace a body function.

Check Your Medicare Plan

Check Coverage and Billing Info

When trying to see if the PureWick system is covered under your Medicare plan you can:

1. Contact Your Plan Provider: Reach out to your Medicare Advantage plan provider to ask if the PureWick urine collection system is covered under your plan.

2. Review Your Plan Documentation: Check your coverage booklets or online resources provided by your plan.

3. Consult Your Healthcare Provider: Get necessary paperwork and support from your doctor to establish medical necessity of the device.

Coverage Limitations

Medicare coverage for external urinary catheters like the PureWick system is not clear cut. Here are some things to consider:

• Original Medicare (Part A and Part B): Original Medicare covers many medical devices but does not typically cover the PureWick urine collection system. Coverage is based on DME criteria and patient need.

• Medicare Advantage Plans: Coverage varies widely by plan. Some plans cover the PureWick system and others do not.

• Medicaid Services: In some cases Medicaid may cover the PureWick system. Medicaid coverage varies by state so check with your state’s Medicaid program.

Billing and HCPCS Codes

Medicare billing for the PureWick system requires the correct coding and HCPCS codes. The PureWick external catheter system including the collection canister and pump tubing must be coded correctly to be covered:

• Specific HCPCS Codes: HCPCS codes are used to bill Medicare for DME items. The correct HCPCS code must be used so the device is recognized and covered.

• Separate Claim Lines: To avoid billing issues use separate claim lines for the different components of the PureWick system, the collector tubing and collection canister.

Cost and Reimbursement

Cash Sales and Discounts

If your Medicare or insurance plan doesn’t cover the PureWick system you can manage costs through:

• Cash Sales: Some medical supply companies offer cash sales of the PureWick system at a discounted rate.

• Discount Programs: Look for discount programs or financial assistance through medical suppliers or organizations that support urinary incontinence patients.

File a Claim and Reimbursement

Filing a claim and getting reimbursed can be a process.

1. File Claims: Make sure you file claims correctly with your insurance provider using the right HCPCS codes.

2. Follow Up on Claims: Follow up with your insurance provider regularly to check on your claims.

3. Consult Coverage Determination Experts: Get advice from local coverage determination experts to ensure all documentation and coding requirements are met.

Downsides of the PureWick System

While the PureWick system has many benefits there are also some drawbacks:

1. Skin Irritation: Prolonged use of the PureWick system can cause skin irritation. Make sure the device is placed flat and check skin conditions regularly.

2. Cost: Without insurance coverage the PureWick system is costly. It’s like paying for a luxury item every month which might not be sustainable for everyone.

3. Limited Mobility: The PureWick system requires the collection canister and pump tubing to be close by. Not the best companion if you like to roam around your house!

4. Privacy: Carrying a PureWick system might not be the most discreet solution for some users. Imagine having a conversation with someone while a small machine hums away in the background – it could be the uninvited guest in your social interactions!

Other Options

Other External Catheters and Collection Devices

If the PureWick system isn’t covered by your insurance or you don’t like it consider:

• Male External Catheter: For male patients there are several types of external catheters that may be covered by Medicare or commercial insurance.

• Indwelling Catheter: An indwelling catheter may be recommended for patients who need a more permanent solution. But that comes with its own set of issues, higher risk of infection.

Urine Collection Starter Sets and Ostomy Supplies

Patients may also consider urine collection starter sets or other ostomy supplies to manage urinary incontinence. These products have different coverage criteria and may be in the prosthetic device benefit category under certain insurance plans.

Patient Comfort

When choosing a urine collection device patient comfort should be the top priority. Devices that are comfortable and easy to use will lead to better compliance and better quality of life. Patients should talk to their healthcare provider to choose devices that are comfortable and manage urinary incontinence.

Correct Coding and Medicare Billing

Correct Coding

Correct coding is key to getting claims submitted. In the case of the PureWick system using the right HCPCS code tells Medicare the device exists and will consider coverage. Incorrect coding will result in claim denials, delays and frustration.

How to Bill Medicare

When billing the PureWick system to Medicare follow these steps:

• Use Specific HCPCS Codes: Make sure to use the correct codes for the PureWick system and its components.

• Follow Medicare Guidelines: Follow Medicare’s billing guidelines including using separate claim lines for different parts of the system.

• Keep Records: Document everything related to the billing process including conversations with insurance provider, submitted claims and responses received.

Using Data in Coverage Decisions

Data in Coverage

Data is key in determining coverage for medical devices like the PureWick system. By analyzing patient outcomes, usage patterns and cost effectiveness Medicare and other insurance companies can make informed decisions on what devices to cover.

How Patients Can Use Data

Patients can use data to advocate for their coverage. By presenting data on the PureWick system’s effectiveness patients can make a stronger case for why it’s necessary. Data on patient comfort, reduced skin irritation and better urinary output can support coverage claims.

Different Types of Catheters

External vs Indwelling Catheters

External urinary catheters like the PureWick system are a non-invasive alternative to indwelling catheters. Indwelling catheters are inserted into the bladder and stay there which increases the risk of infection. External urinary catheters reduce that risk and are more comfortable.

Female External Catheters

The PureWick system is designed as a female external catheter. It sits outside the body collecting urine non-invasively. That’s why it’s a great option for many female patients with urinary incontinence.

Other External Catheters

Besides the PureWick system there are other external catheters available each with its own benefits. Patients should talk to their healthcare provider to determine which catheter is best for them based on their condition and needs.

Using the PureWick System

Placement and Usage

For best results the PureWick system should be placed on a flat surface near the patient. Make sure the collection device is in the right position to prevent leaks and accurate urine output measurement.

Maintenance and Cleaning

Regular maintenance is important to extend the life of the PureWick system. The collection canister and pump tubing should be cleaned regularly to prevent bacteria and odors buildup. Follow the manufacturer’s guidelines for maintenance to keep the system working properly.

Prescription

Patients usually need a prescription to get the PureWick system. A healthcare provider must evaluate the patient’s condition and determine an external urinary catheter is needed. Having a prescription also helps establish medical necessity for insurance coverage.

Henry Beltran’s Take

Henry Beltran, owner of Medicare Advisors Insurance Group LLC says “Every patient is unique. When it comes to medical insurance for products like the PureWick system it’s not just about what’s covered. It’s about what works for the patient. We help patients navigate their options whether it’s through Medicare or commercial insurance to get them the best and most affordable care.”

Bottom Line

Navigating Medicare coverage for the PureWick urine collection system requires knowing the rules and how to play them. Whether through Medicare, Medicaid or commercial insurance the goal is to get access to non-invasive solutions for urinary incontinence. By exploring different urine collection systems, understanding the codes and talking to insurance companies patients can make informed decisions to improve their comfort and quality of life.

Incontinence supply solutions like the PureWick system can help manage urinary incontinence but it’s important to understand the insurance landscape. By being informed, reviewing plan details and considering all options patients and caregivers can make the best decisions for their healthcare needs. After all it’s about finding that balance between medical necessity, cost and patient well-being.

Local Coverage Determinations in Medicare

What are Local Coverage Determinations (LCDs)

Local Coverage Determinations (LCDs) are decisions made by Medicare Administrative Contractors (MACs) about what items and services are covered in their area. These can vary and affect whether a device like the PureWick system is covered. Check the relevant LCDs when trying to get coverage for a specific device.

How LCDs Affect PureWick System Coverage

For the PureWick system to be covered the local MAC must include it in their LCD. This inclusion is based on medical necessity and data analysis showing the device works. If a local MAC doesn’t include the PureWick system in their LCD coverage will be denied.

The Social Security Act and Medicare Coverage

Social Security Act and Medicare

The Social Security Act is the basis for Medicare coverage, including what is a prosthetic device. This act has guidelines for covering devices like the PureWick system under the prosthetic device benefit if the device replaces a body function.

Prosthetic Device Benefit

Devices covered under the prosthetic device benefit are those that replace a body function. The PureWick system which manages urinary output can be considered under this category if it meets the criteria in the Social Security Act.

Types of Supplies and Coverage

Urological Supplies

Urological supplies are devices used to manage urinary incontinence such as external catheters, collection canisters and other related products. These supplies are important for patients with chronic urinary conditions and can impact quality of life.

Ostomy Supplies and How They Fit In

The PureWick system is not an ostomy product but understanding how ostomy supplies are covered under Medicare can give insight into how similar products are covered. Ostomy supplies are covered under Medicare Part B as DME like the PureWick system.

Proper Documentation Matters

Medical Necessity Documentation

Proper documentation of medical necessity is key to getting Medicare to cover the PureWick system. Healthcare providers must clearly state why the patient needs the device and how it will be used to manage their condition. This documentation supports the claim and increases chances of approval.

Prescription and Coverage

A valid prescription from a healthcare provider is a requirement for coverage. The prescription should include the patient’s condition, the recommended device (like the PureWick system) and why it’s needed for their care.

How to Appeal Denials

What to Do if Denied

If the PureWick system is denied, patients can:

1. Review the Denial: Understand why the claim was denied and what’s missing.

2. Submit Additional Information: Send in any missing information such as letters of medical necessity or data.

3. File an Appeal: Follow the appeal process outlined by Medicare or the insurance company. This usually involves a formal appeal letter and any additional evidence.

The Appeal Process

The appeal process for denied claims has multiple levels starting with a redetermination by the MAC and then potentially a hearing in front of an administrative law judge. Patients will need to be prepared to provide all the evidence to support their need for the PureWick system.

Patient Advocacy Resources

Patient Advocates

Patient advocates can be a big help for patients getting coverage for devices like the PureWick system. They can help with the insurance process, support during appeals and make sure patients have access to the information they need.

Where to Find Advocacy Resources

Patients can find advocacy resources through healthcare providers, non-profit organizations focused on urinary health or Medicare’s beneficiary support programs. These resources can provide information on coverage options, appeal process and patient rights.

Long-term Cost

Long-term Cost of Use

Long term use of the PureWick system can be costly if not covered by Medicare or commercial insurance. Patients should consider the ongoing costs, such as replacement parts like collection canisters and pump tubing.

Benefits vs. Cost

While the initial and ongoing cost of the PureWick system may be high, the benefits of better quality of life, reduced skin irritation and better urinary incontinence management should also be considered. These benefits will justify the cost for many patients especially when other options are not suitable.

Conclusion: Be Informed

Be Informed

To understand coverage for the PureWick system you need to be informed about Medicare policies, commercial insurance options and local coverage determinations. Patients should seek out information, talk to their healthcare provider and use the resources available to make the best decision for their health.

Be Proactive

Patients with urinary incontinence should be proactive in their care, including trying different devices, understanding coverage and talking to their healthcare provider. By doing so they can find solutions that work for them and their comfort.