Medicare Coverage for Specific Types of Home Medical Equipment
Bi-Level Devices/Respiratory Assist Devices**
- For a
respiratory assist device to be covered, the treating physician or
healthcare provider must fully document in your medical record symptoms
characteristic of sleep-associated hypoventilation, such as daytime
hypersomnolence, excessive fatigue, morning headaches, cognitive
dysfunction, dyspnea, etc.
- A
respiratory assist device is covered if you have a clinical disorder
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 Complex Sleep Apnea (CompSA), or
- (IV)
hypoventilation syndrome
- If you
are diagnosed with Obstructive Sleep Apnea, see the coverage criteria for
Positive Airway Pressure Devices below.
- Various
tests may need to be performed to establish one of the above clinical
disorders.
- Three
months after starting your therapy you must return to your doctor or
healthcare provider for a follow-up to confirm the machine is benefitting
you and that you are regularly using the device.
-
- This
must be documented in your doctor or healthcare provider’s notes from
that office visit. Your physician or healthcare provider will be
required to respond in writing to questions regarding your continued use
along with how well the machine is treating your condition.
- If
you are not using your machine for an average of four hours per night per
24-hour period at the time you meet with your doctor or healthcare
provider, then you may be held responsible (via an Advance Beneficiary
Notice) to pay for the rental until you meet this requirement.
- Bi-level
devices are considered to be capped rental items, and they cannot be
purchased outright. You will own the equipment after Medicare makes
13 payments toward the purchase of the equipment.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
- When
at home, you may receive up to a three-month supply of accessories at one
time.
- Your accessories
must be dysfunctional or otherwise compromised in order to be replaced.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
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.
- As
an alternative, Medicare can cover a nipple prosthesis every three
months.
- Mastectomy
bras are covered as needed.
- There
is no coverage for replacement prostheses due to wear and tear before the
specified time frames. However, Medicare will cover replacement of these
items due to:
-
- Loss
- Irreparable
damage, or
- Change
in medical condition (e.g. significant weight gain/loss)
- You
are allowed only one prosthesis per affected side, others
will be denied as not medically necessary even if attempting asymmetry (an
Advance Beneficiary Notice should be provided in this circumstance).
- Mastectomy
sleeves which are used to control swelling 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.
- A
mastectomy bra is covered if the pocket of the bra is used to hold a
covered prosthesis or mastectomy form.
Cervical Traction
- Cervical
traction devices are covered only if both of the criteria below are met:
-
- You
have a musculoskeletal or neurologic impairment requiring traction
equipment.
- The
appropriate use of a home cervical traction device has been demonstrated
to you and you are able to tolerate the selected device.
- Certain
traction devices are considered capped rental items, and they cannot be
purchased outright. You will own the equipment after Medicare makes
13 payments toward the purchase of the equipment.
Commodes**
- A
commode is only covered when you are physically incapable of utilizing
regular toilet facilities. For example:
-
- You
are confined to a single room, or
- You
are confined to one level of the home environment and there is no toilet
on that level, or
- You
are confined to the home and there are no toilet facilities in the home.
- Heavy-duty
commodes are covered if you weigh over 300 pounds.
- Commodes
with detachable arms are covered if your body configuration requires extra
width, or if the arms are needed to transfer in and out of the chair.
- Raised
toilet seats that are used to position hand bars over a regular toilet are
not covered by Medicare.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
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 reimbursed by
Medicare for the prevention of ulcers, prevention of the reoccurrence of
ulcers, treatment of lymphedema or swelling without ulcers.
Continuous Positive Airway Pressure Devices (CPAPs and
Bi-Level Devices for Obstructive Sleep Apnea)**
Continuous Positive Airway Pressure (CPAP) Devices are
covered only if you have Obstructive Sleep Apnea (OSA).
- Medicare
requires that you first meet with your physician or healthcare provider to
discuss your symptoms and risk factors for Obstructive Sleep Apnea.
- After
meeting with your doctor or healthcare provider, you must then have an
overnight sleep study performed in a sleep laboratory or through a
special, in-home sleep test to establish a qualifying diagnosis of
Obstructive Sleep Apnea.
- Your
doctor or healthcare provider may then prescribe a CPAP to treat your
obstructive sleep apnea. Medicare will initially cover a three-month
trial of this equipment. Medicare will also pay for replacement
masks, tubing and other necessary supplies as prescribed by your doctor or
healthcare provider.
- If
during your sleep study (or during your trial period) the CPAP device is
not working for you, or if you cannot tolerate the CPAP machine, your
doctor or healthcare provider may prescribe a different device called a
Bi-Level or a Respiratory Assist Device, and Medicare can consider this
for coverage as well.
- After
using the equipment for three months, 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. Per Medicare, a follow-up face-to-face visit with
your physician or healthcare provider is required to document an improvement
of your symptoms no sooner than 31 days and no later than 91 days from the
set-up date. Data is typically downloaded from your sleep equipment
and must be provided to your doctor or healthcare provider during this
follow-up visit to document that the machine has been used consistently
for at least four hours per night on 70% of nights during a 30-day
consecutive period.
- Talk
with your supplier if you are having problems adjusting to the therapy or
using the equipment every night. There are a lot of variations that
can make the therapy more comfortable for you.
- CPAPs
and Bi-Levels are considered capped rental items, and they cannot be
purchased outright. You will own the equipment after Medicare makes
13 payments toward the purchase of the equipment.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
- When
at home, you may receive up to a three-month supply of accessories at one
time.
- Your
accessories must be dysfunctional or otherwise compromised in order to be
replaced.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
Diabetic Supplies**
- For
diabetics, Medicare covers the glucose monitor, lancets, spring-powered
lancing 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.
- Medicare
will cover insulin pumps and insulin for the pump, for qualified diabetics
who have completed a comprehensive education program. You must have a history of at least
three or more injections per day for six months, documented testing of four
or more checks per day for at least two months, and persistent
complications prior to starting pump therapy.
- Medicare
may also cover approved therapeutic continuous glucose monitors (CGMs) for
qualified diabetics. You must have a history of at least three or more injections
per day, documented testing of four or more checks per day, and a
treatment regimen that necessitates frequent insulin adjustment based on
test results. This therapy also
requires an in-person visit with your physician or healthcare practitioner
prior to ordering the equipment and repeat visits every six months
thereafter. Medicare will not pay for traditional testing supplies once
you own a CGM.
- For
diabetics using a standard glucometer, 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 of need.
-
- If
you test above these guidelines, you are required to be seen and
evaluated by your physician or healthcare provider within six months prior
to receiving your initial supplies from your supplier.
- Every
six months thereafter, your physician or healthcare provider must verify
you are actually testing as frequently as prescribed in their chart notes
to continue getting refills at the higher levels.
- If at
any time your testing frequency changes, your physician or healthcare
provider will need to give your supplier a new prescription.
- Medicare
began a national mail order program in July of 2013 that requires you to
get your diabetic supplies through one of approximately 9, nationally
contracted suppliers for all testing supplies delivered to your home. (Note: This restriction will not apply
during the gap in the competitive bid program between January 1, 2019 and
December 31, 2020.)
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
- When
at home, you may receive up to a three-month supply of regular testing
supplies and one-month supply of insulin pump and CGM supplies at one
time.
- You
must have nearly depleted the supplies on hand to be eligible for
additional products.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
Glasses
- Medicare
covers one complete pair of glasses, after a recent cataract
surgery with intra-ocular lens replacement. The Medicare benefit includes
a frame and two lenses. As an alternative, a pair of contact lenses
can be covered in lieu of glasses.
- For Medicare
beneficiaries that have a condition called aphakia (patients who are born
without an intra-ocular lens, or who have had the lens removed and not
replaced), Medicare will cover glasses, and/or contacts as often as is
medically necessary.
- When
specifically prescribed for a medical condition documented in your medical
chart, Medicare may also cover tint, anti-reflective coating, and/or UV
protection.
Hospital Beds**
- A hospital
bed is covered if you have visited your doctor or healthcare provider and
during an office visit your doctor or healthcare provider documented in
your chart one or more of the following criteria:
-
- You
have 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
- You
require positioning of the body in ways not feasible with an ordinary bed
in order to alleviate pain, or
- You
require 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
- You
require traction equipment which can only be attached to a hospital bed.
- Specialty
beds that allow the height of the bed to be adjusted are covered if you
require this feature to permit transfers to a chair, wheelchair or
standing position.
- A
semi-electric bed is covered if your medical condition requires frequent
changes in body position and/or you have an immediate need for a change in
body position.
- Heavy-duty/extra-wide
beds can be covered if you 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 supplier
usually can apply the cost of the qualifying hospital bed toward the
monthly rental price of the total electric model. You will need to sign an
Advance Beneficiary Notice (ABN) and will be responsible to pay the
difference in the retail charges between the two items every month.
- Hospital
beds are capped rental items, and they cannot be purchased outright.
You will own the equipment after Medicare makes 13 payments toward the
purchase of the equipment.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
Lymphedema Pumps or Pneumatic Compression Devices
- Compression
Pumps are not reimbursed by Medicare for the treatment of
peripheral artery disease or the prevention of venous thrombosis (blood
clots).
- Lymphedema
Pumps are covered for treatment of true lymphedema as a result of:
-
- Primary
Lymphedema which is an inherited disorder that occurs on its own such as
Milroy’s disease, congenital lymphedema due to lymphatic aplasia or
hypoplasia, lymphedema praecox, lymphedema tarda, and similar disorders (relatively
uncommon, chronic conditions), or
- Secondary
lymphedema which is much more common and results from the destruction of,
or damage to, formerly functioning lymphatic channels that may result
from:
-
- radical
surgical procedures with removal of regional groups of lymph nodes (for
example, after radical mastectomy),
- radiation
therapy,
- trauma
- obstruction
caused by tumors,
- lymphatic
filariasis (typically found in developing countries)
- Chronic
Venous Insufficiency (CVI) which results in compression produced by the
leakage of fluids from the venous system in the lower extremities (legs
and feet),
-
- This
condition also presents with hyperpigmentation, stasis dermatitis,
chronic edema and venous ulcers.
- The
incidence of lymphedema from CVI is not well established; however,
Medicare has established guidelines for CVI with one or more venous
stasis ulcers.
- When
lymphedema extends into the chest, trunk or abdomen, a specialty pump can
be considered.
- Before
you can be prescribed a pump, your physician or healthcare provider must
monitor you during a minimum, four-week trial period for lymphedema and
six-week trial for CVI with ulcers.
-
- During
the trial, your doctor or healthcare provider must document the results
of other treatment options including limb elevation, regular exercise,
compression bandage systems or compression garments, dietary
adjustments, and the use of diuretic and similar medications as
applicable.
- Your
doctor or healthcare provider should document pre and post measurements
in your chart notes as each conservative treatment is evaluated.
- If,
during the trial, there is any improvement using these other methods Medicare
will not approve a pump.
- Medicare
will only consider reimbursing for the pump when you have been
unresponsive to the conservative treatment and there is no significant
improvement over the required trial period (the most recent four or six
weeks).
- Lymphedema
Pumps are capped rental items, and they cannot be purchased
outright. You will own the equipment after Medicare makes 13
payments toward the purchase of the equipment.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
Medicare-covered drugs (other than Medicare Part D
coverage)
- All
suppliers of Medicare-covered drugs are required to accept assignment on covered
medications.
- Very
few medications are covered under your Part B benefit. Traditional
Medicare Part B insurance will cover some nebulizer drugs, some infused
drugs that require the use of a pump, specific immunosuppressive drugs,
select oral anti-cancer medications and most parenteral nutrition.
- The
Medicare Part D plans may provide additional coverage of other oral
medications, inhalers and similar drugs.
- You
must have nearly depleted the medication on hand to be eligible for
additional products.
Mobility Products: Canes, Walkers, Wheelchairs, and
Scooters**
- Medicare
policy on mobility products requires that that Medicare funds are only
used to pay for:
-
- Mobility
needs for daily activities within the home
- The lowest level
of equipment required to accomplish these tasks.
- The
most medically appropriate equipment (that meets your
needs, not conveniences)
- Medicare
requires that your physician or healthcare provider and supplier evaluate
your needs and expected use of the mobility product to determine which
item you will qualify for.
- They
must determine the lowest level of equipment to help you be mobile within
your home and 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 supplier 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 (ABN).
- Your
home must be evaluated to ensure it will accommodate the use of any
mobility product.
- A
face-to-face examination with your physician or healthcare provider to
specifically discuss your mobility limitations and need for mobility is
required prior to the initial setup of a power chair, scooter or manual
wheelchair.
- In
some cases, for custom manual chairs and power mobility items you may also
be asked to see a physical therapist or occupational therapist to
determine the best fit and equipment to meet your needs.
- The
majority of all manual and power wheelchairs are considered capped rental
items, and they cannot be purchased outright. If the item selected
is considered capped rental, you will own the equipment after Medicare
makes 13 payments toward the purchase of the equipment.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
Nebulizers**
- Nebulizer
machines, medications and related accessories are usually covered if you
have obstructive pulmonary disease, but can also be covered to deliver
specific medications if you have HIV, cystic fibrosis, bronchiectasis, pneumocystosis,
complications of organ transplants, or for persistent thick or tenacious
pulmonary secretions.
- Nebulizer
machines are considered to be capped rental items, and they cannot be
purchased outright. You will own the equipment after Medicare makes
13 payments toward the purchase of the equipment.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
- You
may obtain up to a three month’s supply of nebulizer medications and
accessories at a time as long as you continue to regularly use the
medications through your machine.
- If at
any time you stop using your medications, please notify your supplier.
- Your accessories
must be dysfunctional or otherwise compromised and medications must be
nearly depleted in order to be replaced or refilled.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
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
- Elastic
garments
Orthopedic Shoes
- Orthopedic
shoes are covered when it is necessary to attach shoe(s) to a medically
necessary leg brace.
- Medicare
will only pay for the shoe(s) attached to the leg brace(s).
- 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,
or
- urostomy
- This
supply is subject to a Medicare restriction called consolidated
billing. If you are receiving care
from a home health agency, where a nurse visits the home periodically to
provide care, the agency must provide all supplies during the 60-day
episode. The agency is responsible
for the supplies even if they are in the home for an unrelated condition.
For this reason, please be sure to alert your supplier of any nurse visits
to your home prior to requesting additional supplies.
- You
may obtain up to a three-month’s supply of wafers, pouches, paste and
other necessary items as needed.
- You
must have nearly depleted the supplies on hand to be eligible for
additional products.
Oxygen**
- Your
doctor or healthcare provider must start with an office visit to discuss
your symptoms before ordering any testing. If your symptoms are
indicative of a chronic lung condition or other disease that requires long
term oxygen therapy, Medicare will likely cover oxygen when the test
results meet the coverage criteria outlined below.
- Oxygen
is not covered for acute illnesses like pneumonia or for exacerbations of
an underlying disease, because this is considered a temporary, acute or
unstable condition.
- Oxygen
is covered if you have significant hypoxemia in a chronic stable state
when:
-
- You
have a severe lung disease or hypoxemia that might be expected to improve
with oxygen therapy, and
- Your
blood gas levels or oxygen saturation levels indicate the need for oxygen
therapy, and
- Your
oxygen study was performed by a physician, qualified lab, other qualified
provider and
- Alternative
treatments have been tried or deemed clinically ineffective.
- Categories/Groups
of oxygen therapy are based on the test results to measure your
oxygen. There are two types of tests that can be used for this
purpose. An Arterial Blood Gas (ABG) test is an invasive procedure
which provides detailed information and a direct measurement of oxygen in
arterial blood (blood that flows through an artery inside your body).
ABG test results are reported in millimeters of mercury (mm Hg). A
saturation test (SAT) is a non-invasive procedure that indirectly measures
oxygen saturation using a sensor typically placed on the ear or
finger. SAT test results are reported in percentages (%). Your lab
test results must meet the following criteria for coverage:
-
- Group
I Criteria: mm Hg ≤ 55, or saturation ≤ 88%
-
- For
these results you must return to your physician or healthcare provider
between 9-12 months after the initial visit to discuss whether your
oxygen therapy should continue for lifetime or a shorter period if the
need is expected to end. Typically, you will not have to be retested
when you return to your physician or healthcare provider for the
follow-up visit.
- Group
II Criteria: 56-59 mm Hg, or 89% saturation
-
- For
these results, you must return for another office visit with your
physician or healthcare provider to discuss your oxygen therapy and, for
these “borderline” results, you will also have to be retested within three
months of the first test to continue therapy for lifetime or the need is
expected to end.
- Group
III Criteria: mmHg ≥ 60 or saturation ≥ 90% is considered to be not
medically necessary.
- Note
on nocturnal oxygen therapy: If you only require the use of oxygen only
during the nighttime, your doctor should rule out obstructive sleep apnea
as a cause for the hypoxemia symptoms you may be experiencing. If
obstructive sleep apnea is a potential factor, Medicare will not cover
oxygen therapy until you have officially had the sleep apnea diagnosed and
treated. When obstructive sleep apnea is a factor, testing for
oxygen can only begin after the apneas are controlled with positive airway
therapy using a CPAP or Bi-PAP. When obstructive sleep apnea is a
factor, you can only be tested in a facility (not in your home).
- Oxygen
will be paid as a rental for the first 36 months. After that time,
Medicare will no longer make rental payments on the equipment. However, if
equipment is still necessary, your supplier will continue to provide the
equipment to you for an additional 24 months. During this two-year service
period, Medicare will pay your supplier for refilling your oxygen
cylinders (if you have gas or liquid systems) and for a semi-annual
maintenance fee.
- After
60 months of service through Medicare, your supplier is not obligated to
continue service, but you may choose to receive new equipment and Medicare
will begin paying for your equipment rental again.
- Per
requirements established by the Affordable Care Act, you must have a
specific office visit with your physician or healthcare practitioner to
assess and document your need for liquid and gas equipment. Your physician
or healthcare practitioner must also provide your supplier with a
compliant written order.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
Parenteral and Enteral therapy**
- Parenteral
therapy requires all or part of the gastrointestinal tract to be missing.
Nutritional formulas must be delivered through a vein for Medicare to
cover this service.
- Enteral
therapy is covered if you cannot swallow or take food orally. Nutrition
must be delivered through a tube directly into the gastrointestinal tract
for Medicare to cover this service.
- Medicare
will not pay for nutritional formulas that are taken orally.
- Specialty
nutrition/formulations can be covered if you have unique needs or specific
disease conditions which are well documented in your physician’s or
healthcare provider’s records. In most cases, you may have to try
standard formulas and document that they are unsuccessful before Medicare
will consider the specialty nutrition.
- Generally
feeding pumps are rented although sometimes they can be purchased outright
or during the course of the rental.
If you choose to continue renting the pump beyond the first 15
months of service, Medicare may reimburse your supplier for a periodic
maintenance fee for the life of the equipment. If you elect to purchase the machine at
any time, you may be responsible for a portion of future repair and
service fees.
- No
more than one-month’s supply of product is allowed at a time.
- You
must have nearly depleted the supplies on hand to be eligible for
additional product.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
Patient Lifts**
- A
lift is covered if transfer between a bed and a chair, wheelchair, or
commode requires the assistance of more than one person and, without the
use of a lift, you would be bed confined.
- An electric
lift mechanism is not covered; because it is considered a convenience
feature. If you prefer to have the electric mechanism, your supplier can
usually apply the cost of the manual lift toward the purchase price of the
electric model. You will need to sign an Advance Beneficiary Notice (ABN)
and would be responsible to pay the difference between the retail charges for
the two items on a monthly basis.
- Patient
lifts are considered to be capped rental items, and they cannot be
purchased outright. You will own the equipment after Medicare makes
13 payments toward the purchase of the equipment.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare provider.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
Seat Lift Mechanisms or Lift Chairs**
- In
order for Medicare to pay for a seat lift mechanism or lift chair, you
must be suffering from severe arthritis of the hip or knee, or have a
severe neuromuscular disease. In addition, you must be completely
incapable of standing up from any chair, but once
standing can walk either independently or with the aid of a walker or
cane. The physician or healthcare provider must believe that the mechanism
will improve, slow down, or stop the deterioration of your condition.
- If
you transfer directly from the seat lift chair to a wheelchair, Medicare will
not pay for the equipment. Once standing, you must be able to functionally
walk to qualify for this equipment.
- Medicare
will only pay for the lift mechanism portion. The chair or furniture portion
of the package is not covered. You will be responsible for paying the full
amount for the furniture component of the chair.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
Support Surfaces**
- Group
1 products are designed to be placed on the top of a standard hospital bed
or home mattress. They can utilize gel, foam, water or air, and are covered
if you are:
-
- Completely
immobile, OR
- Have
limited mobility or 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 if you have 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 lesser 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 as needed and followed as directed. This product is only
covered while ulcers are still present.) OR
- A
recent myocutaneous flap or skin graft surgery for an ulcer on the trunk
or pelvis within the last 60 days where you were immediately placed on
Group 2 or 3 support surface prior to discharge from the hospital. (You must
have been discharged within the last 30 days.)
- A
physician or healthcare provider must make monthly assessments as to
whether continued use of the equipment is required. Sometimes your
physician or healthcare provider may order a home healthcare nurse to
visit you to make these assessments. Note: When nurses are in the home,
remember to alert your supplier if you receive ostomy supplies, wound care
dressings, or catheters. These
supplies must be provided by the home health agency and not your regular supplier
while they are in the home.
- Medicare
will only pay for the rental of a Group 2 product until your ulcers
completely heal. If your ulcers have healed, you must return the
equipment to your supplier or make arrangements to pay for future monthly
rentals privately using an Advance Beneficiary Notice (ABN) document.
- Group
3 products are air-fluidized beds and are only covered if you meet ALL of
the following conditions:
-
- You
have at least one stage III or stage IV pressure ulcer, and
- You
are bedridden or chair bound as the result of limited mobility, and
- In
the absence of an air-fluidized bed you would require
institutionalization, and
- An
alternate course of conservative treatment has been tried for at least
one month without improvement of the wound, and
- All
other alternative equipment has been considered and ruled out.
- A
physician or healthcare provider must assess and evaluate you after
completion of a course of conservative therapy within one month prior to
ordering the Group 3 support surface.
- A
trained adult caregiver must be available to assist you. Medicare does not
cover the cost of hiring a caregiver, or for structural modifications to
your home to accommodate this heavy equipment.
- A
few of the support surfaces are considered eligible for outright
purchase. However, a number of the
support surfaces that Medicare covers are considered to be capped rental
items, and they cannot be purchased outright. If the product is in
the capped rental category, you will own the equipment after Medicare makes
13 payments toward the purchase of the equipment.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
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 pain can be treated with a TENS unit. Medicare will not pay
for the device or supplies when used to treat conditions where the units
have been proven ineffective. These include:
-
- headaches,
- visceral
abdominal pain,
- pelvic
pain,
- TMJ
pain, and
- lower
back pain (except for individuals participating in an approved clinical
trial)
- For
chronic pain sufferers that have had persistent pain for three or more
months in duration, Medicare will pay for a one- or two-month trial rental
to determine if this device will help or alleviate the chronic pain. You
must return to your physician or healthcare provider 30-60 days after your
initial evaluation to discuss how the therapy is working and to authorize
the purchase of this equipment.
- For
acute, post-operative pain sufferers, Medicare will consider rental
payment for a maximum of 30 days. Medicare will deny longer durations as
not medically necessary.
- Your
supplier cannot deliver this product to you without evidence of a recent
office visit with, and a compliant written order from, your doctor or
healthcare provider. If the equipment is subject to these special rules,
your supplier cannot get the documentation at a later date because if they
do, Medicare can never make payment for those products to you or your
supplier when a compliant order is not secured before delivery. So
please be patient with your supplier while they collect the required
documentation from your physician or healthcare provider.
- A
supply allowance can be made once a month as needed, but should be less
frequent for non-daily use.
- Wires
can be replaced once a year, if they become dysfunctional or otherwise
compromised.
- When
at home, you may receive up to a three-month supply of accessories at one
time.
** Some or all of the products in this category may
be subject to competitive bidding depending on where you live. Ask your
supplier for details.
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 or pre-ulcerative calluses
- peripheral
neuropathy with callus formation
- foot
deformity
- poor
circulation in either foot
- You
must have an office visit with your physician or healthcare provider
within six months of receiving new shoes to discuss and document your
diabetes management and why you need these special shoes. This
office visit must be repeated each time you wish to obtain replacement
shoes.
- Only
a physician treating your diabetes can certify your diabetic condition and
complications that require specialty shoes.
- Your
healthcare practitioner or a podiatrist may further evaluate your feet and
order the shoes.
- When
providing you with shoes, your supplier must perform an in-person
evaluation of your foot/feet, and they must verify that your shoes fit
properly.
- Because
of requirements imposed by the Affordable Care Act, and depending on which
product is ordered, your supplier may not be able to deliver this
equipment to you without a recent office visit and compliant written order
from your doctor or healthcare provider. If the equipment is subject to
these special rules, your supplier cannot get the documentation at a later
date because if they do, Medicare can never make payment for those
products to you or your supplier when a compliant order is not secured
before delivery. So please be patient with your supplier while they
collect the required documentation from your physician or healthcare
provider.
Urological Supplies
- Urinary
catheters and external urinary collection devices are covered to drain or
collect urine if you have permanent urinary incontinence or permanent
urinary retention. Permanent incontinence and retention are defined as a
condition that is not expected to be medically or surgically corrected
within three months.
- A
maximum of six catheters may be used per day (up to 200 per month), unless
it is determined that a higher number is medically necessary by your
physician or healthcare provider, and these unique circumstances are
specifically documented in your medical records.
- This supply is subject to a Medicare restriction
called consolidated billing. If you
are receiving care from a home health agency, where a nurse visits the
home periodically to provide care, the agency must provide all supplies
during the 60-day episode. The
agency is responsible for the supplies even if they are in the home for an
unrelated condition. For this reason, please be sure to alert your
supplier of any nurse visits to your home prior to requesting additional
supplies.
- When at home, you may receive up to a three-month
supply at one time.
- You must have nearly depleted the
supplies on hand to be eligible for additional products.
