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.”