Medicare Guide

This information is presented to serve as a resource to both end users and health care professionals to assist in finding answers to questions related to the access of Durable Medical Equipment (DME) through Medicare Part B. Some of the information you can expect to find within our website include:

• What guidelines and policies does Medicare have in place regarding DME items?
• What coverage criteria must be met to qualify for the equipment?
• What information must be obtained and how detailed must this information be?

What you need to know

Medicare policy, equipment qualifications and documentation requirements are absolute and must be satisfied, in full. If the beneficiary does not meet ALL required criteria and/or if the clinical documentation  received does not support that the criteria has been met then other funding arrangements will have to be made before equipment can be provided.

Background

As a condition to receive payment, per Section 6407 of the Affordable Care Act that was implemented July 1, 2013, it is required that certain DME items require a  Face-to-Face  evaluation with the beneficiary. It is also required that the physician document that the encounter for the item did occur and within the allotted time frame, 6 months of the Detailed Written Order. The face-to-face may be performed by physician, PA, NP or CNS, but upon completion the face-to-face must be approved and signed by the physician.

Medicare has strict guidelines and policies, some of which are:

1. Medicare pays for the least costly alternative, and each lower level item must be ruled out. The following are a few examples but not limited to

• If your prescription is for a walker it must be documented why any lower level item will not suit your need such as a cane or crutch, OR
• If your prescription is for a lightweight wheelchair then there must be documentation that explains why a standard wheelchair will not meet the medical need.

2. The need is for “In the Home.” If the equipment is not needed to get around inside the home, it will not meet Medicare coverage criteria. The following are a few examples but not limited to

• If the equipment is needed for long distances outdoors, OR
• If the equipment is used as a support or rest system in public.

3. Medicare does not cover any item in the bathroom, i.e.:

• Shower chairs
• Tub transfer benches
• Etc.

For a detailed list of all Qualifications and Required Documentation, Please click on the requesting item below.

Patient Lifts

Seat Lift Chairs

Bedside Commodes

Support Surfaces

Hospital Beds and Accessories

Mobility Equipment