MEDICARE EQUIPMENT COVERAGE
Medicare coverage can be categorized in the following areas: Bathroom, Bedroom, Incontinence, Mastectomy, Respiratory Equipment, Walking Aids, Wheelchairs, Wheelchair Accessories.
Med-Response will attempt to summarize items in these categories indicating if they are or are not covered. We hope this is helpful to you.
BATHROOM:Medicare does not pay for these items:
Elevated Toilet Seats
Tub
Transfer Chairs
Bath
and Shower Benches
Toilet, Tub, or Wall Grab Bar
BEDROOM:
This is a capped rental item.
a). The patient requires a bed height that is different than a fixed
b). Patient requires immediate and/or frequent changes in body
This is a capped rental item. All of the criteria listed below must be
This item is not covered by Medicare.
This item is not covered by Medicare.
This is a capped rental item and is non-assigned.
** Patient lift
slings are private pay.
This
item is Purchase only and is non-assigned.
The
patient is highly susceptible to pressure sores.
The patient must meet one or more of the following criteria:
The
patient requires positioning of the body in ways not possible
with an bed because of his/her diagnosis with the condition
expected to last at least one month. The
patient requires traction which can only be attached to a
hospital bed. The
patient requires the head of the bed to be elevated more than
30 degrees most of the time due to CHF, COPD, or aspiration.
Pillows and wedges will not work. The
patient requires a certain positioning of the body that is not
possible with a regular bed. Both
of these criteria must be met:
height hospital bed to permit easier transfers to a chair,
wheelchair or standing position.
position.
met for coverage. The patient is susceptible to decubitus ulcers. A
written order must be obtained prior to delivery of item. If the
patient has ulcers, the size and stage must be reported. Physician
is supervising the use of this item.
Coverage must include all of the following: When
transferring the patient between bed and chair,
commode or wheelchair the assistance of more than
one person is needed.
Without a lift, the patient would be bed confined.
Medicare will pay part of the cost if: Physician
specifies that he/she will supervise use of the
mattress
These items are not covered by Medicare:
Pads, Pants, & Diapers , Underpads
MASTECTOMY:
Medicare pays 80% every two-year period for
silicone breast
prosthesis or for foam-filled forms.
Your secondary/supplemental insurance may pay the 20%.
Medicare pays 80% for 2 bras every 6 months.
Your secondary/supplemental insurance may pay the 20%.
Medicare pays 80%.
WALKING AIDS:Purchase Only.
A physician's order is required,
indicating potential for
ambulating.
Purchase Only.
A physician's order is required showing
potential for
ambulating.
Purchase only.
A physician's prescription is required indicating a potential
for ambulating.
It must be indicated that the patient requires stability not
provided by a cane.
Purchase Only.
A physician's prescription
is required indicating a potential
for ambulating.
Purchase Only.
For coverage, a physician's prescription
is required indicating
a potential for ambulating.
WHEELCHAIRS:
This
is a capped rental item and is covered by Medicare if the
following criteria are met:
Patient mobility at home is required by
wheelchair
If adjustable height arms are needed
then the following must be met:
a) patient must be in the wheelchair at least 4 hours per day
b) patient
needs an arm height different from fixed arm height
This is a capped rental item and is covered by Medicare if the
following criteria are met:
Patient mobility at home is required by
wheelchair
Elevated Leg rests are covered when one
or more criteria are met:
a) The patient
has a musculoskeletal condition that prevents
90 degree flexion
of the knee.
b) The patient has a cast or brace that would prevent the 90
degree flexion of the
knee.
The patient
must have wheelchair for mobility in the home.
The hemi
feature is covered when the following criteria are met:
a) The patient must be unable to propel a standard
wheelchair with
his/her feet on the ground.
b)
The patient must be able to self propel, using feet in a lower seat
height(hemi) wheelchair.
For
adjustable height arms, additional information is
required as follows:
a) The patient must be in the wheelchair at least 4 hours a day.
b)
The patient must be able to self propel, using his/her feet in a lower
seat
height (hemi) wheelchair.
This is a capped rental item.
The following criteria must be met for coverage
of a lightweight wheelchair:
The patient requires a wheelchair for
mobility in the home.
The patient is capable of
self-propulsion of this type of chair
The patient cannot self-propel in a
standard wheelchair.
These are capped rental items. The patient's height, weight, and
hip size must be documented.
Coverage results if the following criteria
are met:
The patient requires a wheelchair
for mobility in the home.
The patient must be in a
wheelchair at least 4 hours a day.
(Note: criteria for coverage for an Extra Heavy-Duty Wheelchair
are the
same as for the Heavy-Duty
Wheelchair. The only difference between
the two is that the Extra
Heavy-Duty is for patients weighing over 300 lbs.)
The patient requires a wheelchair for
mobility within the home.
The patient requires a wheelchair that
is not available in a
manufactured wheelchair frame.
Special documentation must be provided.
RESPIRATORY:
Portable oxygen is covered by itself or in conjunction with a stationary
oxygen system and will be covered if the following conditions are met:
All
criteria must be met for stationary oxygen systems as described below
Patient must be
ambulatory in the home.
This is a capped rental item. Coverage exists when:
A
Physician's prescription indicates that the patient's ability to breathe
is impaired.
This is a rental item only and is a capped rental item. One or more of the
following criteria must be met:
Unconscious or semi-conscious
state.
Cancer or surgery of the throat
Malfunctioning of the swallowing
muscles
A tracheotomy.
Patient cannot clear secretions
easily.
The following criteria must be met for coverage of this item:
The patient
must have tests performed measuring the content of
oxygen in the blood, taken on room air. Either PO2 or SaO2
(saturation)
has to be documented.
PO2 of 55 or less must
exist, SaO2 of 88% or less monitored during sleep
or exercise for a period of one year.
A PO2 of 56-59, or
SaO2 of 89% with a chronic lung diagnosis for 3 months.
One of the following must exist: CHEF or Erythrocythemia or Cor
Pulmonale.
Re-testing is required during the 61st to the 90th day of therapy for continual
coverage.
Prescribed liter flow
and hours of use, and the type of O2 system must be
supplied.
Testing must be
completed within 48 hours prior to the patient's dismissal from
the hospital.
For coverage, the following must be documented:
The patient had a 6-7 hour sleep
test.
The patient experienced at least
30 episodes of apnea during
a 6-7 hour sleep test.
Each apnea episode lasted at least
10 seconds in duration.
Nasal BIPAP S and ST
These are capped rental items and
must meet the criteria for Nasal CPAP
as described above and the following:
BIPAP ST requires a physician's prescription
Both BIPAP ST and S must be prescribed when a Nasal CPAP is not sufficient
therapy for the
condition.
Med-Response, Inc.
P.O. Box 3225
Bluefield, WV 24701
Phone: (800) 635-1948 Fax: (304) 589-6319
EMAIL US: medresponse@medresponse.com
TOP
10/28/05 Last Updated
