Pediatric incontinence can be a source of stress and anxiety that parents would rather try to cover up instead of seeking assistance. Treating incontinence has been shown to greatly improve the child’s self-esteem1. However, with the help of a medical diagnosis and by qualifying to receive incontinence supplies through insurance can greatly assist with properly managing or treating your child’s condition. Here’s how to make sure your incontinence products are covered by insurance.
How to Get Pediatric Diapers Covered through Medicaid
This information reviewed by Dr. Jay Levy MD, FAAP, FACS
First, What Is Incontinence?
Incontinence is the inability to control voiding the bladder, resulting in involuntary loss of urine, leakage, or inability to fully empty the bladder. Incontinence in children may be caused by a variety of conditions from developmental delays, constipation, or physical disabilities. Sometimes incontinence can be treated and will eventually go away with proper treatment and behavior training. However, in some cases, it can only be managed.
Diurnal incontinence occurs when children have accidents during the day and is considered to be normal until they reach the normal age of potty training around age 3.
Enuresis or wetting the bed at night is considered to be normal until the age of 6.
Unfortunately, many private insurers do not cover incontinence supplies.
Incontinence & Medicaid
Medicaid will cover monthly incontinence supplies if the diapers are considered to be a medical necessity due to a specific diagnosis. Children with special needs have higher rates of all type of incontinence than children without developmental or behavioral impairments2. To have pediatric incontinence supplies covered the following criteria must be met:
The child health of Medicaid includes EPSDT, Early Periodic Screening, Diagnosis, and Treatment. This is to ensure the right care to the right child at the right time. It also ensures that children under the age of 21 enrolled in Medicaid receive age-appropriate screening, preventative services, and treatment services to discover and properly treat the condition as early as possible.
Part of this provision includes “home health care” which is largely interpreted to include medical supplies and equipment needed for a child to treat a diagnosed condition, including incontinence supplies.
A signed medical necessity letter or prescription from a member’s treating physician/nurse practitioner, physician assistant within the last 12 months.
Accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnoses/conditions, to include the member’s overall health status.
Diagnosis/condition causing incontinence.
The number of times per day the physician/NP/PA has ordered incontinence supplies to be used.
The number of disposable supplies requested per month.
Maximum authorization of up to 3 months at a time with updated clinical notes.
Medical guidelines for the authorization of incontinence supplies which include: diapers, briefs, pull-ups, liners, underpads, and emollients.
Medical Conditions That May Cause Incontinence Include:
Intellectual And Developmental Delay
Conditions such as Down syndrome that are linked to cognitive delays may impact a child’s ability to learn proper toileting techniques or cause a physical condition making it difficult to properly control their bowel movements. By visiting the doctor parents can learn toilet training technique, determine if incontinence is caused by a physical abnormality and if it can be treated or managed.
Signs of incontinence may include failure to make it to the restroom in time, the inability to recognize the need to go or communicate the need, difficulty emptying the bladder and leakage. While children with developmental delays may learn to properly use the restroom over the course of a few months, some will need incontinence supplies into adulthood.
Autism is the developmental condition that impairs the ability to communicate and socially interact with others. Depending on where a child falls on the spectrum, incontinence may present itself in a variety of ways from the inability to control the bladder, not realizing the urge to go, or sensing a sudden urge to go and not making it to the restroom on time. Children with autism also may be physically unable to make it to the toilet in time.
Connecting with a doctor will help determine if the child requires specialized toilet training, if the condition is caused by a physical abnormality, and will help put a treatment plan together. For some children with autism, incontinence can be treated over a few months to a few years, but some will need to manage incontinence into adulthood.
Neurogenic bladder is caused by neurological damage and contributes to flaccid and spastic bladder dysfunction. It can contribute to the inability to fully empty the bladder, frequent urination, the sudden urge to urinate, the lack of sensation to urination, and uncontrolled loss of urine.
Visiting a doctor may result in the use of medications to help the bladder properly function, but in a majority of cases, neurogenic bladder can only be managed and contributes to lifetime incontinence.
Spina Bifida is a birth defect in which the spine doesn’t properly form during fetal development, resulting in neural tube defects. The neural tube develops into the spinal cord and the tissues that enclose it.
Depending on the severity of spina bifida a child has, they may not even know they have a disorder or could have a physical disability. Based on where they fall in this range, they could experience nerve damage that causes bladder dysfunction for involuntary loss of urine, spasms that cause leakage or fail to feel the sensation or urge to go.
Paraplegia is paralysis of the lower legs, lower body, and pelvic organs. This type of paralysis is often caused by brain injuries, spinal injury, or disease. Depending on how much damage is caused to the nerves leading to the pelvic organs, patients may experience an overactive bladder, spasms resulting in leaking, or difficulty fully emptying the bladder. Patients may also experience the inability to recognize the urge to go or the inability to make it to the toilet in time when the urge strikes.
The cause and severity of paraplegia can affect incontinence symptoms. While patients often face incontinence for a lifetime, in a few cases it can become alleviated or less severe with the use of medication or surgery.
Cerebral Palsy is a group of movement disorders that appear in early childhood. Symptoms include poor posture, muscle weakness, poor coordination, loss of sensation, and more. It contributes to incontinence in a variety of ways. From causing loss of urine due to bladder spasms, enuresis, the inability to recognize the urge to go, frequent urination, and bladder leakage.
In some cases, cerebral palsy causes a delay in the ability to learn proper toileting by a few years and often experience enuresis. It’s also common to experience incontinence symptoms into adulthood.
Crohn’s disease is an inflammatory bowel disease (IBD). The inflammation of the digestive tract can lead to severe abdominal pain, diarrhea, fatigue, and more. In children and adults, Crohn’s disease can result in inflammation of the rectum, making it difficult to hold liquid stool and causing liquid incontinence.
Thymic Hypoplasia, also known as DiG, a condition in which the thymus is underdeveloped or involuted. There are two main types, Ataxia–telangiectasia and hypocalcemia which can cause a variety of conditions such as mental delays, physical disorders, immune diseases, abnormal development, retardation, and more.
The type and severity of hypoplasia a patient has may contribute to the severity of their incontinence symptoms from leaking, not being able to make it to the restroom in time, failing to recognize the urge to go and more. In some cases, thymic hypoplasia can be cured, but it can also last well into adulthood.
Congenital Adrenal Hyperplasia (CAH)
Congenital adrenal hyperplasia is a group of rare inherited autosomal recessive disorders that affects a child’s growth and development. It’s primarily characterized by impacting the adrenal glands at the top of the kidneys and being deficient of enzymes needed to make specific hormones.
Symptoms include genital defects, rapid growth, early puberty, a lack of cortisol, a lack of potassium and an imbalance of bodily fluids. CAH generally causes incontinence in females and can contribute to leakage, frequent urination, and uncontrolled voiding. With the right medications and oftentimes surgery, patients can become continent. However, many patients still leak when pressure is placed on the bladder as adults.
Diabetes Insipidus is a rare disease when the body fails to properly balance fluids, resulting in excessive urination. Usually constant thirst and a high water intake are accompanying symptoms. Patients are often at risk for dehydration, loss of salt, and loss for electrolytes.
They also suffer from frequent urination, not being able to reach the toilet in time, and bed wetting. However with the proper medication to help the body retain water diabetes insipidus can be managed.
Hirschsprung’s disease or megacolon is a disease present at birth that causes the large intestine to be unable or to have difficulty passing stools. As a result, stools collect as the color expands. Babies may begin to vomit, become fatigued, have a swollen stomach, become gassy, or experience diarrhea.
Surgery often helps the colon function normally but can result in a delay in toilet training.
10% of all babies born with megacolon suffer with life long incontinence symptoms.
Attention Deficit/Hyperactivity Disorder (ADHD)
ADHD is a disorder that causes the inability to control impulses or to pay attention. The patient may also be restless and extremely active. Patients often have trouble at school and difficulty socializing.
The inability to concentrate may contribute to high rates of incontinence among children with ADHD. They often leak, void their bladder, and wet the bed because they have a lower rate of compliance when it comes to toilet training or managing their symptoms. They also may not notice the urge. Generally with proper training children can become continent after a few extra months or years of practice compared to children without ADHD.
Post Traumatic Stress Disorder (PTSD)
PTSD a psychological disorder defined as difficulty recovering after witnessing or experiencing a terrifying event, such as a wreck. Symptoms include flashbacks, nightmares, and severe anxiety.
While PTSD isn’t known to cause incontinence, but the two conditions seem to be associated. The heightened stress and anxiety after a traumatic event or an overreaction to events could cause leaking or total voiding of the bladder. Children may need to use incontinence supplies while attending therapy and may require medication to work through their emotional and physical symptoms. Treatment could last from months to years.
What You Need From The Doctor
If your child is suffering from one of these conditions and incontinence you will need a prescription for pediatric incontinence products. You will also need a signed letter of medical necessity that explains why the products are needed. The letter will include a list of how many per day their physician/NP/PA ordered the supplies to be used and how many disposable supplies will be needed on a monthly basis. This letter must be signed within the last 12 months.
You will also need accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnosis to include your child’s overall health status.
Products That Assist With Incontinence Include:
Diapers – Diapers are absorbent underwear that children can pull off and on themselves. They do not have removable tabs. They catch urine and feces to prevent leaks and have a waterproof outer layer.
Briefs – Briefs are similar to diapers but have a bit more protective padding and removable tabs. They are more suited for children with physical disabilities that cause them to remain seated or in bed.
Pull-Ups – Pull-Ups are similar to diapers, but have an elastic band around the waist, making them easier for children to pull on and off themselves. They’re typically designed for older children.
Liners – Liners are placed in the bottom of underwear and have adhesive to stick in place. They contain absorbent layers to catch leaking urine. These are great for catching bladder leakage.
Underpads – Also known as chux, underpads are used to protect furniture such as mattresses or car seats from leaks. They have a soft absorbent layer on top, with a waterproof bottom. They make clean ups easier, as they can simply be chucked in the trash after use.
Disposable wipes – Disposable wipes are your best friend. These moist towelettes can help you clean your child
Emollients – Emollients are cosmetic items used to prep the skin to moisturize, lubricate, and protect it from rashes.
Depending on your child’s condition these products could be needed for varying lengths of time. Sometimes incontinence supplies are needed for a few months, a few years, or during their entire life. It’s best to work with your doctor to determine the necessity for incontinence products and to put together a proper treatment and management plan.
Dr. Jay Levy
Dr. Jay Levy is Medical Director at Aeroflow Healthcare and a pediatric urologist based in Charlotte, N.C. He is board certified in Urology by the American Board of Urology and also earned the subspecialty certification in Pediatric Urology. Dr. Levy holds a Doctor of Medicine from the University of Texas Southwestern Medical School and a Bachelor of Science in biology from the University of Texas. He has completed residency programs at the University of Texas Southwestern Medical Center at Dallas, the University of Pennsylvania School of Medicine and the Mayo Clinic School of Medicine.
- Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scandinavian Journal of Urology and Nephrology. Supplemental 183:79-82 , , , , (1997)
- Gontard A (2013) Urinary incontinence in children with special needs. Nature Review Urology 10, 667-674