The updated urological supplies local coverage determination (LCD) published by the Medicare DME MAC contractors includes a significant change for patients with spinal cord injuries (SCI).
The LCD was published Nov. 13, with an effective date of Jan. 1, 2026.
“The LCD incorporates finalized revisions, as a result of the LCD reconsideration process and written comments received during the comment period for the proposed LCD,” the DME MACs said in their announcement.
CMS noted that the revised LCD clarifies “that documentation of spinal cord injury (SCI) in the medical record is sufficient to establish eligibility for sterile catheter kits.”
The LCD itself now says in its summary of evidence that while SCI is “commonly viewed as a problem of motor control and sensory loss, resulting in at least partial paralysis,” it also impairs a number of bodily processes, including autonomic function.
“Emerging data show that pathogens more easily infect individuals with SCI, because SCI disrupts neural and humoral control of immune cells, culminating with the development of SCI-induced immune deficiency syndrome,” the LCD continued. Additionally, the LCD referenced research studies that “broadly support the diminished immune status of individuals with SCI compared to those without SCI. … Emerging data suggest that a dysfunctional immune response in the bladder may significantly contribute to the propensity to develop infections after SCI.”
The LCD said, “The body of evidence shows individuals diagnosed with SCI experience immune suppression, which is directly and indirectly consequential to spinal cord damage. While the magnitude is greatest at higher spinal levels, immunosuppression occurs regardless of the vertebral level affected or the severity of SCI.”
In a bulletin sent to stakeholders on Nov. 14, the American Association for Homecare (AAHomecare), said, “Of particular importance to suppliers, the accompanying policy article clarifies that documentation of an SCI diagnosis alone is sufficient to establish that a beneficiary is immunocompromised for the purposes of qualifying for sterile catheter kits (A4297, A4353).
“The clarification streamlines coverage by allowing documentation of SCI alone to automatically qualify a beneficiary as immunocompromised for sterile catheter kits, allowing patients access to sterile kits without requiring them to have two urinary tract infections.”
The LCD also included new HCPCS codes for hydrophilic catheters with an effective date of Jan. 1, 2026. The new codes were announced by the Centers for Medicare & Medicaid Services in October 2024.
— A4295: Intermittent urinary catheter; straight tip, hydrophilic coating, each.
— A4296: Intermittent urinary catheter; coude (curved) tip, hydrophilic coating, each.
— A4297: Intermittent urinary catheter; hydrophilic coating, with insertion supplies.
