Does Medicare or Medicaid Cover Purewick Catheter Systems?

What Medicare and Medicaid Cover for Purewick

Medicare Part B covers Purewick systems as durable medical equipment (DME) when a doctor prescribes one for urinary incontinence. You pay 20% of the approved amount after you meet your Part B deductible; Medicare pays the remaining 80%. Medicaid coverage varies by state — some states cover Purewick fully, some cover it partially, and some do not cover it at all. Your state Medicaid program makes that decision independently.

The key requirement for both programs is a written prescription from your doctor stating medical necessity. Without that prescription, neither Medicare nor Medicaid will pay. The prescription must come before you order the system, not after.

If you have a Medicare Advantage plan (Part C) instead of Original Medicare, your coverage may differ. Some Advantage plans cover Purewick; others do not. You need to check your specific plan's formulary or call the plan directly.

Key Takeaways

Medicare Part B covers Purewick as durable medical equipment when prescribed by a doctor, and you pay 20% of the approved cost after meeting your deductible.
Medicaid coverage for Purewick depends entirely on your state; you must contact your state Medicaid office or your managed care plan to learn whether it is covered.
A written prescription from your doctor stating medical necessity is required by both Medicare and Medicaid before you order the system.
Medicare Advantage plans have their own coverage rules separate from Original Medicare, so you must check your plan documents or call your plan directly.
If your state Medicaid does not cover Purewick, you may still find lower prices through manufacturer information programs or by asking your doctor about alternatives.

How to Get a Medicare-Covered Purewick System

Start by talking to your doctor about whether Purewick is medically necessary for your situation. If your doctor agrees, ask them to write a prescription that includes the medical reason — for example, "severe urinary incontinence" or "mobility limitations preventing toileting." The prescription must be on the doctor's letterhead and signed.

Once you have the prescription, contact a DME supplier that is enrolled with Medicare. Not all medical supply companies are Medicare-approved DME suppliers. You can search for one at the Medicare.gov supplier directory or ask your doctor's office for a referral. When you call, tell the supplier you have a prescription and ask whether they accept Medicare assignment (meaning they bill Medicare directly and you pay only your 20% coinsurance).

The DME supplier will submit your prescription and medical information to Medicare for review. Medicare will decide whether to cover it based on the medical necessity statement. This review typically takes one to two weeks. Once approved, you receive the system and begin paying your coinsurance.

Medicaid Coverage by State

Medicaid is run by each state, so coverage rules are different in every state. Some states classify Purewick as a covered DME; others do not list it in their covered supplies; still others require prior authorization from the state before a supplier can dispense it.

To find out whether your state covers Purewick, contact your state Medicaid office directly. You can find your state office at Medicaid.gov or by calling your local health department. Have your Medicaid member ID ready. If you are enrolled in a Medicaid managed care plan, call the plan's customer service number instead — they manage coverage decisions for your state.

If your state Medicaid does cover Purewick, the process is similar to Medicare: you need a doctor's prescription, and you submit it to a Medicaid-enrolled DME supplier. Copayments or coinsurance vary by state and by your specific plan.

What Happens If Your Plan Does Not Cover Purewick

If Medicare, Medicaid, or your Medicare Advantage plan denies coverage, you have options. First, ask your doctor whether they can provide additional medical documentation to support a coverage appeal. Some denials are reversed when the doctor submits more detailed clinical notes.

Second, contact the Purewick manufacturer directly to ask about patient information programs. Many medical device manufacturers offer systems at reduced cost or free to people who cannot afford them and meet income requirements. The manufacturer can tell you whether you may have access to.

Third, ask your doctor about alternative products that your insurance does cover. Other catheter systems, absorbent products, or urinary management devices may be covered and may work for your situation.

Medicare Advantage Plan Coverage

If you have a Medicare Advantage plan, your coverage for Purewick is determined by that plan, not by Original Medicare. Some Advantage plans do cover it; many do not. Your plan's coverage rules are in your Evidence of Coverage (EOC) document, which you received when you enrolled.

To find out quickly, call the customer service number on the back of your Advantage plan card and ask whether Purewick is a covered DME. If it is, ask whether you need prior authorization or a referral from your primary care doctor. If it is not covered, ask whether the plan covers any alternative incontinence management systems.

If your Advantage plan does not cover Purewick but you believe it should, you can file a coverage appeal. Your plan must tell you how to appeal when they deny coverage.

Documents You Will Need

Gather these items before you contact a DME supplier:

A written prescription from your doctor that states the medical reason for Purewick and is dated within the past 12 months.
Your Medicare card (front and back) or your Medicaid member ID card.
Your doctor's name, phone number, and fax number so the supplier can verify the prescription.
Your insurance information, including any secondary coverage you may have.
Your current address and phone number.

If you are appealing a denial, you will also need the denial letter from your insurance company, which explains why coverage was refused.

Common Reasons Coverage Is Denied

Medicare and Medicaid deny Purewick coverage most often because the doctor's prescription does not clearly state medical necessity, or because the prescription is too old (usually more than 12 months). Make sure your doctor's prescription includes a specific medical reason, not just "incontinence" — for example, "severe urinary incontinence with limited mobility" is stronger.

Some denials happen because the DME supplier is not enrolled with your insurance program. Always confirm that the supplier you choose is Medicare-approved or Medicaid-enrolled in your state before you place an order.

Medicaid denials sometimes occur because the state has not approved Purewick as a covered item, or because your specific managed care plan has excluded it. In those cases, an appeal may not reverse the decision, but it is worth trying if your doctor believes the system is medically necessary.

Frequently Asked Questions

Do I need prior authorization from Medicare before I order Purewick?

No. Medicare does not require prior authorization for Purewick. You need a doctor's prescription, and the DME supplier submits it to Medicare for coverage review, but you do not have to call Medicare first. Some Medicaid plans do require prior authorization, so check with your state Medicaid program or managed care plan.

What if my doctor says Purewick is medically necessary but my insurance denies it?

You can file a coverage appeal with your insurance company. Include your doctor's statement of medical necessity with your appeal. If your insurance denies the appeal, you may also ask your doctor to file an appeal on your behalf, which sometimes carries more weight. The appeal process takes two to four weeks.

Will I pay the same amount whether I use Medicare or Medicaid?

No. Medicare Part B charges 20% coinsurance after your deductible. Medicaid copayments and coinsurance vary by state and by your specific plan. Some state Medicaid programs charge no copay for DME; others charge a small amount. Call your state Medicaid office to learn your cost.

Can I use a Purewick system that I bought myself and then submit the receipt to Medicare for reimbursement?

No. Medicare does not reimburse you for equipment you purchase on your own. You must have the prescription and use a Medicare-approved DME supplier. The supplier bills Medicare directly, and you pay only your coinsurance.

What if I have both Medicare and Medicaid?

If you have both, Medicare is your primary payer and Medicaid is secondary. The DME supplier will bill Medicare first. If Medicare covers Purewick, Medicaid may cover your coinsurance, depending on your state's rules. Call your state Medicaid office to ask whether they cover Medicare coinsurance for DME.

This guide is for general information only and is not medical, financial, legal, or other professional advice. For decisions specific to your situation, consult a qualified professional. See our Editorial Policy.