Three-Way Indwelling Catheter and Continuous Irrigation of Indwelling Catheter
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
A three-way indwelling catheter either alone or with other components may be considered medically necessary when continuous catheter irrigation is medically necessary.
A three-way indwelling catheter not meeting the criteria as indicated in this policy is considered not medically necessary
Supplies for continuous irrigation of a catheter may be considered medically necessary if there is a history of obstruction of the catheter and the patency of the catheter cannot be maintained by intermittent irrigation and catheter changes.
Supplies for medically necessary continuous bladder irrigation include a three-way Foley catheter, irrigation tubing set, and sterile saline or sterile water.
More than one (1) set of irrigation tubing per day, for continuous catheter irrigation, is considered not medically necessary.
Therapeutic irrigation solutions containing antibiotics and chemotherapeutic agents are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of the service cannot be established by the available published peer-reviewed literature.
Irrigating solutions such as acetic acid or hydrogen peroxide, which are used for the treatment or prevention of urinary obstruction, are considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-review literature.
Continuous irrigation for greater than two (2) weeks is considered not medically necessary. Continuous irrigation for periods that exceed two (2) weeks require medical documentation. Any other indication not listed above is considered not medically necessary.
Three (3)-way indwelling catheter and/or continuous irrigation not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
