Medicare Coverage for specific types of home medical equipment
BiPaps/Respiratory Assist Devices
- For a respiratory assist device to be covered, the treating physician must fully document in the patient’s medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc.
- A respiratory assist device is covered for those patients with clinical disorder groups characterized as (I) restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities), (II) severe chronic obstructive pulmonary disease (COPD), (III) central sleep apnea (CSA), or (IV) obstructive sleep apnea (OSA).
- Various tests may need to be performed to establish the above diagnosis groups.
- Three months after starting your therapy, both your physician and you will be required to respond to questions in writing regarding your continued use along with how well the machine is treating the condition.
Breast Prostheses
- Breast Prostheses are covered after a radical mastectomy. Medicare will cover:
- One silicone prosthesis every two years or a mastectomy form every six months.
- Mastectomy bras are covered as needed.
- There is no coverage for replacement prostheses due to wear and tear before the listed time frame. However, Medicare will cover replacement of these items due to:
- Loss
- Irreparable damage, or
- Change in medical condition (e.g. significant weight gain/loss)
- Patients are allowed only one prosthesis per affected side, others will be denied as not medically necessary even if attempting asymmetry (need ABN).
- Mastectomy sleeves are not covered in the home setting because they do not meet Medicare’s definition of a prosthesis; however, it is possible that they may be covered under the hospital per diem if you request one during your hospital stay.
- Triangle Aftercare does not carry breast prostheses, but has several local options to which we refer our patients.
Cervical Traction
- Cervical traction devices are covered only if both of the criteria below are met:
- The patient has a musculoskeletal or neurologic impairment requiring traction equipment.
- The appropriate use of a home cervical traction device has been demonstrated to the patient and the patient tolerated the selected device.
Commodes
- A commode is only covered when the patient is physically incapable of utilizing regular toilet facilities. For example:
- The patient is confined to a single room, or
- The patient is confined to one level of the home environment and there is no toilet on that level, or
- The patient is confined to the home and there are no toilet facilities in the home.
- Heavy-duty commodes are covered for patients weighing over 300 pounds.
Compression Stockings
- Gradient compression stockings worn below the knee are covered only when used for the treatment of open venous stasis ulcers. They are not covered for the prevention of ulcers, prevention of the reoccurrence of ulcers or treatment of lymphedema without ulcers.
CPAPs
- Continuous Positive Airway Pressure (CPAP) Devices are covered only for patients with obstructive sleep apnea (OSA).
- You must have an overnight sleep study performed in a sleep laboratory to establish a qualifying diagnosis. Home and mobile sleep labs/studies are not accepted.
- Medicare also will pay for replacement masks, cannulas, tubing and other necessary supplies.
- After three months of use, you will be required to verify if you are benefiting from using the device and how many hours a day you are using the machine.
Diabetic Supplies
- For diabetics, Medicare covers the glucose monitor, lancets, spring-powered devices, test strips, control solution and replacement batteries for the meter.
- Medicare does not cover insulin injections or diabetic pills unless covered through a Medicare Part D benefit plan.
- Diabetics can obtain up to a three month supply at a time.
- Medicare will approve up to one test per day for non-insulin dependent diabetics and three tests per day for insulin-dependent diabetics without additional verification.
- Patients who test above these guidelines are required to be seen and evaluated by their physician within six months of ordering these supplies. In addition, patients must provide their provider with evidence of compliant testing every six months to continue getting refills at the higher levels.
- Any time your testing frequency changes, your physician needs to give your provider a new prescription.
- Triangle Aftercare does not carry diabetic supplies, but we have agreements with several organizations to whom we routinely refer our patients.
Glasses
- One complete pair after the last cataract surgery:
- frames
- two lenses
- tint, anti-reflective coating, UV (only when the doctor specifically orders these services for a medical need)
Hospital Beds
- A hospital bed is covered if one or more of the following criteria (1-4) are met:
- The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or
- The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
- The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out, or
- The patient requires traction equipment which can only be attached to a hospital bed.
- Specialty beds that allow the height of the bed to vary are covered for patients that require this feature to permit transfers to a chair, wheelchair or standing position. It is very unusual that Medicare will approve this. Typically patients want this for the benefit of their caregiver, this is not a suitable reason according to Medicare.
- A semi-electric bed is covered for a patient that requires frequent changes in body position and/or has an immediate need for a change in body position. Typically a respiratory related diagnosis is required.
- Heavy-duty/extra-wide beds can be covered for patients that weigh over 350 pounds.
- The total electric bed is not covered because it is considered a convenience feature. If you prefer to have the total electric feature, your provider usually can apply the cost of the semi-electric bed toward the monthly rental price of the total electric model by using an Advance Beneficiary Notice. You would be responsible to pay the difference in the retail charges between the two items every month.
Lymphedema Pumps
Medicare-covered drugs (other than Medicare Part D coverage)
- As of February 2001, all providers of Medicare-covered drugs are required to accept assignment on these items.
- Traditional Medicare will cover nebulizer drugs, infused drugs, immunosuppressive drugs, oral anti-cancer medications and parenteral nutrition.
Mobility Products: Canes, Walkers, Wheelchairs, and Scooters
- General Coverage Guidelines:
- Essentially the new Mobility Assistive Equipment regulations will ensure that Medicare funds are used to pay for:
- Mobility needs for daily activities within the home
- Least costly alternative/lowest level of equipment to accomplish these tasks.
- Most medically appropriate equipment (to meet the needs, not the wants)
- Medicare requires that your physician and provider evaluate your needs and expected use of the mobility product you will qualify for.
- They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions:
- Will a cane or crutches allow you to perform these activities in the home?
- If not, will a walker allow you to accomplish these activities in the home?
- If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home?
- If not, will a scooter allow you to accomplish these activities in the home?
- If not, will a power chair allow you to accomplish these activities in the home?
- Keep in mind if you have another higher level product in mind that will allow you to do more beyond the confines of the home setting, you can discuss with your provider the option to upgrade to a higher level or more comfortable product by paying an additional out of pocket fee using the Advance Beneficiary Notice select the product you like best.
- A face-to-face examination with your physician is required prior to the initial setup of a power chair or scooter.
- House must accommodate the use of any mobility product.
Nebulizers
- Nebulizer machines, medications and related accessories are usually covered for patients with obstructive pulmonary disease, but can also be covered to deliver specific medications to patients with HIV, CF, brochiectasis, pneumocystosis, complications of organ transplants, or for persistent thick or tenacious pulmonary secretions.
Non-covered items (partial listing):
- Adult diapers
- Bathroom safety equipment
- Hearing aides
- Syringes/needles
- Van lifts or ramps
- Exercise equipment
- Humidifiers/Air Purifiers
- Raised toilet seats
- Massage devices
- Stair lifts
- Emergency communicators
- Low Vision Aides
- Grab bars
Orthopedic Shoes
- Orthopedic shoes are covered when it is necessary to attach the shoe(s) to a leg brace.
- However, Medicare will only pay for the shoe(s) attached to the leg braces.
- Medicare will not pay for matching shoes, or for shoes that are needed for purposes other than for diabetes or leg braces.
Ostomy Supplies
- Ostomy supplies are covered for people with a:
- colostomy
- ileostomy
- urostomy
- Patients can obtain up to a three month’s supply of wafers, pouches, paste and other necessary items at a time.
- Triangle Aftercare does not carry most ostomy supplies, but we have agreements with several organizations to whom we routinely refer our patients.
Oxygen
- Covered for patients with significant hypoxemia in the chronic stable state when:
- patient has a chronic lung condition or disease or hypoxemia that might be expected to improve with oxygen therapy, and
- patient’s blood gas levels or oxygen saturation levels indicate the need for oxygen therapy, and
- alternative treatments have been tried or deemed clinically ineffective.
- Categories/Groups are based on the test results to measure your oxygen:
- I 55≤= mmHg, or 88%≤ saturation
- For these results you must return to your physician 12 months after the initial visit to continue therapy for lifetime or until the need is expected to end.
- II 56-59 mmHg, or 89% saturation
- For these results, you must be retested within 3 months of the first test to continue therapy for lifetime or until the need is expected to end.
- III ≥60 or ≥90% not medically necessary
- Medicare is currently not paying for this equipment beyond a 36 month period. There is, however, heavy debate in Congress about changing this.
Parenteral and enteral therapy
- Parenteral therapy requires all or part of the gastrointestinal tract be missing. Nutritional formulas are delivered through a vein. Triangle Aftercare does not carry parenteral equipment, but we have agreements with several organizations to whom we routinely refer our patients.
- Enteral therapy is covered for patients who cannot swallow or take food orally. Nutrition must be delivered through a tube directly into the gastrointestinal tract.
- Medicare will not pay for nutritional formulas that are taken orally.
Patient Lifts
- A lift is covered if transfer between bed and a chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the patient would be bed confined. Medicare must also have paid for or be paying for a hospital bed for the patient.
- An electric lift mechanism is not covered; because it is considered a convenience feature. If you prefer to have the electric mechanism, your provider can usually apply the cost of the manual lift toward the purchase price of the electric model by using an Advance Beneficiary Notice. You would be responsible to pay the difference in the retail charges between the two items.
Seat Lift Mechanisms
- In order for Medicare to pay for a seat lift mechanism, patients must be suffering from severe arthritis of the hip or knee, or have a severe neuromuscular disease. In addition they must be completely incapable of standing up from any chair, but once standing they can walk either independently or with the aid of a walker or cane. The physician must believe that the mechanism will improve, slow down or stop the deterioration of the patient’s condition.
- Transferring directly into a wheelchair will prevent Medicare from paying for the device. Medicare will not pay for the lift mechanism if they are also paying for a wheelchair. The two, according to Medicare are contraindicated.
- Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and the patient will be responsible for the full amount of the chair.
Support Surfaces
- Group 1 products are designed to be placed on top of a standard hospital or home mattress. They can be utilize gel, foam, water or air, and are covered for patients that are:
- Completely immobile OR
- Have limited mobility with any stage ulcer on the trunk or pelvis (and one of the following):
- impaired nutritional status
- fecal or urinary incontinence
- altered sensory perception
- compromised circulatory status
- Group 2 products take many forms, but are typically powered pressure reducing mattresses or overlays. They are covered for patients with one of three conditions:
- Multiple stage II ulcers on the pelvis or trunk while on a comprehensive treatment program for at least a month using a Group 1 product, and at the close of that month, the ulcers worsened or remained the same. (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR
- Large or multiple Stage III or IV ulcers on the trunk or pelvis (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR
- A recent myocutaneous flap or skin graft for an ulcer on the trunk or pelvis within the last 60 days who were immediately placed on Group 2 or 3 support surface prior to discharge from the hospital and the patient has been discharged within last 30 days.
TENS Units
- TENS units are covered for the treatment of chronic intractable pain that has been present for at least three months or more, and in some cases for acute post-operative pain.
- Not all types of pains can be treated with a TENS unit. TENS units have proven ineffective in treating headaches, visceral abdominal pains, pelvic pains, and TMJ pains, and therefore Medicare will not pay for the device when used to treat these conditions.
- For chronic pain sufferers, Medicare will pay for a one or two month trial rental to determine if this device will alleviate the chronic pain. You must return to your physician exactly 30-60 days after initial evaluation to authorize the purchase of this equipment.
- For acute post-operative pain sufferers, Medicare will consider rental payment for a maximum of 30 days. Any duration longer than that will require individual consideration.
- Medicare track record on payment for these items is not good, and Triangle Aftercare will not accept assignment for TENs units.
Therapeutic Shoes
- Special therapeutic shoes, inserts and modifications can be covered for diabetic patients with the following foot conditions:
- previous amputation of a foot or partial foot
- history of foot ulceration
- peripheral neuropathy with callus formation
- foot deformity
- poor circulation in either foot
Urological Supplies
- Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months.
