Insurance Coverage for Incontinence

Pete Health Guide
  • I used to have wonderful health insurance. Low deductible and pretty much covered whatever the doctor ordered as long as it was within the policy. If it wasn't in the policy (for example, the Botox injections I get for urge incontinence) it was fairly easy to request coverage. Might have to fight for it, but in the end, if it was reasonable, they would cover it.

     

    I know that over time health care costs have risen, and insurance companies, while trying to make us believe that they are in business to take care of their policyholders, are actually in business to make a profit. I understand this. It's a business and, from the research that I have done, their profit margin is pretty slim.

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    My current insurance is more expensive, the deductibles are much higher, but the worst aspect is the fact that there are four companies that I must deal with, depending on my health care needs and that of my children:

     

    • One company for doctor's visits, procedures, etc.
    • Another company for prescription medication, not including any injected medications, such as insulin;
    • A third company for injected medications;
    • A fourth company for behavior/mental issues;

     

    Because of my tendency toward chronic bladder infections, I have had pyelonephritis in the past. As prophylaxis against this, in addition to an oral antibiotic, I perform weekly bladder washes with the antibiotic gentamicin in saline. Obviously I have to use a catheter to instill the medication, and I, because I am a "difficult cath" I use a Foley so the catheter will stay in while I get the medication ready. I don't get the medication ready ahead time because sometimes I can't get the catheter in and don't want to waste the medicine.

     

    My insurance refuses to pay for the gentamicin and saline because I don't inject it. It's not terribly expensive, so I just pay for it myself. I had plenty of catheters and I try to re-use them.

     

    Now I'm running low on catheters and, while I have a prescription from my urologist for them, I'm having trouble getting coverage. The insurance company now wants to know the following:

     

    • ICD code for the condition (chronic bladder infection)
    • CPT code for the procedure (bladder instillation)
    • A code for the catheter

     

    While the medication is relatively inexpensive, the catheters may be more than $30 apiece. I do try to re-use them, but this can be pretty uncomfortable because the balloon never completely deflates. This means the catheter diameter is always larger, and therefore more uncomfortable, when re-used.

     

    My insurance company has paid quite a bit of money for the care of my family, but with the policy I have I have paid a lot out of pocket as well. It is inexplicable to me to be quibbling over what is probably less than $100 month.

     

    I will probably have to ask my doctor to get involved, as I don't think my insurance company will accept the codes from me. In the end, it is worth it to me to continue, so I will probably have to buy them myself!

Published On: October 04, 2011