Medicare Coverage Guide For Home Medical Equipment

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 patients condition.

Transferring directly into a wheelchair will prevent Medicare from paying for the device.

Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.

Your provider is required to have a detailed written order or CMN from your physician before they can provide you with this equipment; otherwise the equipment will be denied.

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.

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 send their provider evidence of compliant testing (e.g. a testing log) every six months to continue getting refills at the higher levels.

If at any time your testing frequency changes, your physician will need to give your provider a new prescription.

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, bronchiectasis, pneumocystosis, complications of organ transplants, or for persistent thick or tenacious pulmonary secretions.

Patients can obtain up to a three months supply of nebulizer medications and accessories at a time.

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.

Commodes

A commode is only covered when the patient is physically incapable of utilizing regular toilet facilities.For example:
1. The patient is confined to a single room, or
2. The patient is confined to one level of the home environment and there is no toilet      on that level, or
3. 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.

Ostomy Supplies

Ostomy supplies are covered for people with a:

colostomy

ileostomy

urostomy

Patients can obtain up to a three months supply of wafers, pouches, paste and other necessary items at a time.

Positive Airway Pressure Devices

(CPAPs and Bi-Level Devices for Obstructive Sleep Apnea)
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 of Obstructive Sleep Apnea. In March of 2008, home sleep testing was approved as an acceptable means of diagnosing this condition when your physician deems this testing is appropriate.

Medicare will also pay for replacement masks, tubing and other necessary supplies.

Hospital Beds

A hospital bed is covered if one or more of the following criteria (1-4) are met:

1. 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

2. The patient requires positioning of the body in ways not feasible with an ordinary bed      in order to alleviate pain, or

3. 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

4 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.

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.

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 (ABN). You would be responsible to pay the difference in the retail charges between the two items every month.

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 Part B insurance will cover some nebulizer drugs, some infused drugs using 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

Mobility Products: Canes, Walkers, Wheelchairs, and Scooters

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 (ABN) to 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.

Your home must be evaluated to ensure it will accommodate the use of any mobility product.

You may also be asked to see a physical therapist or occupational therapist to determine the best fit and equipment selection.

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

Parenteral and enteral therapy

Parenteral therapy requires all or part of the gastrointestinal tract be missing. Nutritional formulas are delivered through a vein.

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.

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 (ABN). You would be responsible to pay the difference in the retail charges between the two items.

Patient lifts are a capped rental item.

Support Surfaces

Group 1 products are designed to be placed on top of a standard hospital or home mattress. They can 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.

A physician or healthcare professional must make monthly assessments as to whether continued use of the equipment is required.

Your provider is required to have a detailed written order from your physician before they can provide you with this equipment; otherwise the equipment will be denied.

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.

Your provider is required to have a detailed written order or CMN from your physician before they can provide you with this equipment; otherwise the equipment will be denied.

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.

A maximum of six catheters may be used per day (200/month) for qualified, intermittent catheterizations. The actual quantity that you receive will be based on your physician’s judgment and prescription. Either you or a caregiver must be able to perform the catheterization.

Sterile intermittent catheterization kits are only covered when one of the following five situations exist:

The patient resides in a nursing facility, or

The patient has radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization, or

The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only), or

The patient has had distinct, recurrent urinary tract infections (formally diagnosed via urine cultures), while on a program of sterile intermittent catheterization and sterile lubricant, twice within the 12-months prior to the initiation of sterile intermittent catheter kits.

he patient is immunosuppressed, for example (not all-inclusive):

On a regimen of immunosuppressive drugs post-transplant,

On cancer chemotherapy,

Has AIDS,

Has a drug-induced state such as chronic oral corticosteroid use

For indwelling catheters, one insertion tray and one maintenance service is covered per month, or

A maximum of 35 external male catheters will be covered per month, unless a higher number is deemed medically necessary.

A maximum of 1 metal cup and 1 pouch will be covered for external female catheters per week.

External catheters are not covered for patients already using indwelling catheters.

When at home, you may receive up to a 3-month supply at one time.

Cervical Traction

Cervical traction devices are covered only if both of the criteria below are met:

1. The patient has a musculoskeletal or neurologic impairment requiring traction      equipment.

2. The appropriate use of a home cervical traction device has been demonstrated to the      patient and the patient tolerated the selected device.