UnitedHealthcare® Medicare Advantage
Policy Guideline
URINARY DRAINAGE BAGS (NCD 230.17)
Guideline Number: MPG337.02
Table of Contents
Page
INSTRUCTIONS FOR USE .......................................... 1
POLICY SUMMARY .................................................... 1
APPLICABLE CODES ................................................. 1
REFERENCES ........................................................... 2
GUIDELINE HISTORY/REVISION INFORMATION ........... 2
Approval Date: July 13, 2016
Related Medicare Advantage Policy Guideline

Urological Supplies
Related Medicare Advantage Coverage Summary

Durable Medical Equipment (DME), Prosthetics,
Corrective Appliances/Orthotics (Non-Foot
Orthotics) and Medical Supplies Grid
INSTRUCTIONS FOR USE
This Policy Guideline is applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its
affiliates for health care services submitted on CMS 1500 forms and, when specified, to those billed on UB04 forms
(CMS 1450), or their electronic comparative. The information presented in this Policy Guideline is believed to be
accurate and current as of the date of publication.
This Policy Guideline provides assistance in administering health benefits. All reviewers must first identify member
eligibility, any federal or state regulatory requirements, Centers for Medicare and Medicaid Services (CMS) policy, the
member specific benefit plan coverage, and individual provider contracts prior to use of this Policy Guideline. When
deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific
benefit plan document may differ greatly from the standard benefit plan upon which this Policy Guideline is based. In
the event of a conflict, the member specific benefit plan document supersedes this Policy Guideline. Other Policies and
Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Policies and Guidelines
as necessary.
UnitedHealthcare follows Medicare coverage guidelines and regularly updates its Medicare Advantage Policy Guidelines
to comply with changes in CMS policy. UnitedHealthcare encourages physicians and other healthcare professionals to
keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier
website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or
regulatory changes directly from CMS and/or your local carrier. This Policy Guideline is provided for informational
purposes. It does not constitute medical advice.
POLICY SUMMARY
Overview
Urinary drainage bags can be either leg drainage bags or bedside drainage bags. They may be either multi-use or
single use systems. The multi-use and the single use bags have a system that prevents urine backflow. The single use
system is non-drainable.
Guidelines
There is insufficient evidence to support the medical necessity of a single use system bag rather than the multi-use
bag. A single use drainage system is subject to the same coverage parameters as the multi-use drainage bags.
Urinary collection and retention system are covered as prosthetic devices that replace bladder function in the case of
permanent urinary incontinence.
APPLICABLE CODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in
this guideline does not imply that the service described by the code is a covered or non-covered health service.
Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws
that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or
guarantee claim payment. Other Policies and Guidelines may apply.
Urinary Drainage Bags (NCD 230.17)
Page 1 of 2
UnitedHealthcare Medicare Advantage Policy Guideline
Approved 07/13/2016
Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc.
HCPCS Code
A4357
Description
Bedside drainage bag, day or night, with or without antireflux device, with or without
tube, each (Bundled/Excluded Code)
A4358
Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each
(Bundled/Excluded Code)
A5102
Bedside drainage bottle with or without tubing, rigid or expandable, each
(Bundled/Excluded Code)
A5112
Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each
(Bundled/Excluded Code)
Modifier
KX
GY
Description
Requirements specified in the medical policy have been met
Item or service expected to be denied as not reasonable and necessary
REFERENCES
CMS National Coverage Determinations (NCDs)
NCD 230.17 Urinary Drainage Bags
CMS Local Coverage Determinations (LCDs)
LCD
DME
L33803 (Urological Supplies)
CGS: AL, AR, CO, FL, GA, LA, IL, IN, KY, MI, MN, MS, NC, NM, OH, OK, PR,
SC, TN, TX, VA, VI, WI, WV
Noridian: AK, AS, AZ, CA, CT, DC, DE, GU, HI, IA, ID, KS, MA, MD, ME, MO,
MT, ND, NE, NH, NJ, NV, NY, OR, PA, RI, SD, UT, VT, WA, WY, MP
L5080 (Urological Supplies) NHIC
Retired 09/30/2016
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
L11566 (Urological Supplies) CGS
Retired 09/30/2016
AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, PR, SC, TN, TX, VA, VI, WV
L11581 (Urological Supplies)
Noridian Retired 09/30/2016
AK, AS, AZ, CA, GU, HI, IA, ID, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA,
WY, MP
L27219 (Urological Supplies) NGS
Retired 09/30/2016
IL, IN, KY, MI, MN, OH, WI
CMS Articles
Article
A52521 (Urological Supplies)
DME
CGS: AL, AR, CO, FL, GA, LA, IL, IN, KY, MI, MN, MS, NC, NM, OH, OK, PR,
SC, TN, TX, VA, VI, WI, WV
Noridian: AK, AS, AZ, CA, CT, DC, DE, GU, HI, IA, ID, KS, MA, MD, ME, MO,
MT, ND, NE, NH, NJ, NV, NY, OR, PA, RI, SD, UT, VT, WA, WY, MP
A25230 (Urological Supplies) NHIC
Retired 09/30/2015
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
A25620 (Urological Supplies) CGS
Retired 09/30/2015
AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, PR, SC, TN, TX, VA, VI, WV
A25377 (Urological Supplies)
Noridian Retired 09/30/2015
AK, AS, AZ, CA, GU, HI, IA, ID, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA,
WY, MP
A47236 (Urological Supplies) NGS
Retired 09/30/2015
IL, IN, KY, MI, MN, OH, WI
CMS Benefit Policy Manual
Chapter 15; § 120 Prosthetic Devices (Page 127)
Transmittal
Transmittal 3520, Change Request 9481, Dated 05/02/2016 (Durable Medical Equipment Prosthetics, Orthotics and
Supplies (DMEPOS) Healthcare Common Procedure Coding System (HCPCS) Code Jurisdiction List (Pages 6 & 8))
GUIDELINE HISTORY/REVISION INFORMATION
Date
07/13/2016
Action/Description

Annual review
Urinary Drainage Bags (NCD 230.17)
Page 2 of 2
UnitedHealthcare Medicare Advantage Policy Guideline
Approved 07/13/2016
Proprietary Information of UnitedHealthcare. Copyright 2016 United HealthCare Services, Inc.