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Jan 30, 2024

UnitedHealthcare catheter exclusion leaves patients, physicians in state of confusion

Merritt Davis Merritt Davis has spent the last few months of toddlerhood

Merritt Davis

Merritt Davis has spent the last few months of toddlerhood battling with an insurance company. Or, rather, her mom and dad have. The 15-month-old blue-eyed toddler from Charlotte, N.C., was born with a rare form of spina bifida, a birth defect in which her spine and spinal cord didn't form properly. One of Merritt's complications is a common one called neurogenic bladder: her spinal cord and bladder don't communicate well, leaving her unable to completely drain her bladder on her own.

Merritt's parents, Brian and Jenna Davis, empty her bladder by inserting a catheter four times per day. Merritt's urologist, Dr. Winifred Owumi, explained that this process of intermittent catheterization is essential to Merritt's health, or she could end up in the hospital with urinary tract infections, kidney damage and, ultimately, kidney failure. Kidney failure is a leading cause of death in patients with spina bifida.

The Davises, who have insurance through an employer, could manage Merritt's catheter care until they switched their health benefits from Blue Cross and Blue Shield of Georgia, an Anthem plan, to perhaps the only commercial health insurer that doesn't cover basic urinary catheters: UnitedHealthcare.

Unlike Medicare, most Medicaid programs and most commercial insurers, UnitedHealthcare—the nation's largest insurer—excludes urinary catheters from coverage for many commercial plans, lumping them in the same category as other excluded disposable supplies like elastic bandages and gauze.

Merritt Davis and her parents, Brian and Jenna.

The Davises and the care team at the Charlotte-based Children's Urology of the Carolinas have gone through the tedious back and forth process of appealing UnitedHealthcare's denial with no luck. They have little reason to believe UnitedHealthcare will change its determination. This isn't Owumi's first patient to be denied coverage for catheters by the insurer.

"It's not elective; it's not a cosmetic treatment," Owumi said of using urinary catheters. "I’ve never heard of that before in my training: that it's possible for insurance to refuse to pay for something that's essential to your care. It's not, ‘Oh we don't cover those in this situation.’ It's ‘We just don't cover that.’ "

UnitedHealthcare has a reputation among urologists and medical supply distributors for its long-standing exclusion of urinary catheters. There are blog posts, tweets and Reddit discussions among patients dealing with the policy.

A UnitedHealthcare spokeswoman said only that it covers catheters for Medicare and Medicaid patients, but that coverage for commercially insured members depends on the plan. While she said UnitedHealthcare could not comment on specific patients, Modern Healthcare reviewed multiple denial letters the Davises received from the insurer. UnitedHealthcare also did not respond to questions for this story as to why it denies coverage for catheters or whether the exclusion is meant to trim costs.

Stories abound of insurers denying coverage for an out-of-network emergency room visit, a high-cost drug, or some potentially life-saving medication deemed too experimental, leaving patients on the hook for huge bills or without the treatment they desired. But there are fewer stories detailing situations in which insurers deny coverage for seemingly small, relatively inexpensive items like urinary catheters, even though such an exclusion can have big consequences for patients who need them.

Since the 1970s, intermittent catheterization has been the standard way to manage a person's inability to empty their bladder, which can be a side effect of spina bifida, multiple sclerosis, spinal cord injuries or other conditions. Researchers say more than 300,000 people in the U.S. use intermittent urinary catheters. Patients instead could use an indwelling catheter, which remains inside the body, but that might come with higher risk of infection.

One way or another, people have to drain their bladders. "Think of a bladder that doesn't empty as sort of a stagnant pond," explained Dr. Brian Stork, a general urologist in Muskegon, Mich. "If you allow that stagnant pond not to drain, over time you get bacterial growth and urinary tract infections," adding that the urine could also reflux into the kidneys and cause damage.

For a patient who catheterizes several times daily, the price tag for their treatment could be several thousands of dollars if they use a new one each time. Manufacturers and many urologists, including Owumi, tell their patients to use a new catheter each time to avoid introducing more bacteria into the bladder, especially if, like Merritt, they have already suffered multiple urinary tract infections. The cost of treating a UTI is far more than a single catheter, totaling around $200 in an outpatient setting versus $2,000 in an emergency department, a 2013 study by Henry Ford Health System showed.

Emily Spiteri, a 34-year-old legislative analyst in Minnesota who has been intermittently catheterizing since first grade because of her spina bifida, explained that she used to hoard catheters and reuse them over and over when she was insured by UnitedHealthcare through her husband's employer. She is now insured by Minnetonka, Minn.-based Medica, which covers the bulk of the cost of her intermittent catheters.

"When I didn't have coverage for my catheters, I had very bad UTIs," Spiteri said. "I had to go to the ER. I tried to sterilize them, but I just could not afford to not reuse them."

Spiteri is pushing for the Spina Bifida Association of America to prioritize expanding insurance coverage of catheters in its lobbying efforts. The association said the UnitedHealthcare plan for its employees covers catheters, but would not allow Modern Healthcare to see its plan documents.

UnitedHealthcare's catheter exclusion is out of sync with the rest of the insurance industry. One executive at a major U.S. catheter supplier said he couldn't point to another with a similar policy, though there are other insurers that require very detailed documentation from a doctor before they will cover a more advanced type of catheter. The executive, who spoke on background because the company does business with UnitedHealthcare, said patients who don't have insurance coverage for catheters must buy them from online retailers who specialize in cash-pay transactions.

An Aetna official said the insurer covers urinary catheters when medically necessary. Cigna and Anthem did not respond to questions about their catheter coverage.

Steve Gottlieb, president of New York-based urological supplies company Summit Express Medical Supply, said he had to stop serving all UnitedHealthcare commercial customers because of its policy exclusion. Summit Express published an urgent notice on its website in 2014 alerting customers of the exclusion and warning that other companies may follow suit. Indeed, Gottlieb said he's noticed other insurers reducing the number of more advanced catheters they will cover per month.

Government health programs have long covered catheters. In December 2007, the Veterans Affairs Department sent a letter to clinicians recommending that "catheters identified as single-use devices should not be reused in any setting. Patients should be provided with an adequate number of catheters to use a sterile catheter each catheterization." The VA noted the U.S. Food and Drug Administration considers urinary catheters to be single-use devices, as do catheter manufacturers.

A few months later, Medicare began covering up to 200 basic urinary catheters per month and one packet of lubricant per catheterization. Before that, the program covered four catheters per month, which required patients to clean and reuse them. While UnitedHealthcare considers catheters to be disposable medical supplies, Medicare considers them a prosthetic device that replaces a body part that's not working.

While most payers are on the same page about catheter coverage, there's limited research and much debate about whether patients can safely reuse them, which would lower the cost burden for a patient whose insurance doesn't cover catheters.

One influential review of evidence by researchers at the University of Southampton concluded that there is no convincing evidence that the rate of urinary tract infections is affected by whether the patient reuses catheters or uses a new sterile one each time. But that study, which is often cited in other research, was withdrawn from publication because of possible errors in data analysis. Still, there are other studies that conclude the use of a new sterile catheter does not decrease the frequency of bacteria in patients with neurogenic bladder.

The Centers for Disease Control and Prevention's guidelines also state that the "clean technique," or the reuse of catheters after washing them, is acceptable, though it notes that more research is needed to figure out how best to clean and store intermittent catheters.

On the flip side, a 2014 review, which was funded by a catheter manufacturer, found that literature favored single-use catheters to reduce urinary tract infections and urethral trauma. Another 2019 literature review in the Canadian Urological Association journal similarly found that single-use catheters were considered to impose a lower risk of infection in most studies reviewed. Other researchers have noted that in lieu of conclusive evidence, clinicians should go with the patient's catheter preference.

Dr. John Wiener, a pediatric urologist at the Duke University School of Medicine who treats at least two patients who have been denied coverage for catheters by UnitedHealthcare, said he has patients who have reused catheters for years and never gotten urinary tract infections. However, he said there are some patients who are prone to infection who do better using a new catheter each time.

Whether UnitedHealthcare should cover urinary catheters is a difficult question that depends on whether you think insurance should cover everything or just big expenditures, like costly hospitalizations and surgeries, Wiener said, adding, "But given that all other carriers cover this and it's part of routine care, I think United is a little out of line by no longer covering something that is an important part of a patient's care."

UnitedHealthcare did not respond to a question about whether it has any plans to eliminate its policy exclusion. Some sources predicted it would take a lot of loud and angry patients before a change is made.

Depending on the type, intermittent catheters cost between $1 and $3. Patients may also need to buy packets of lubrication separately. So a year's supply of catheters alone could cost as much as $4,400. But even patients who reuse catheters need several new ones per month.The cost will burden the Davises, but they will shoulder it because they have no choice. Other patients and families may not be able to do the same.

"The catheters are only one element of cost to us," Brian Davis said. Merritt "has a urologist, a neurosurgeon, she has a MRI coming up at the end of this month. We make enough money that if we absolutely had to we could buy our supplies without losing our house. But there must be other families out there that are in a similar situation who don't have the same resources."

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