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:
• 1. You have a musculoskeletal or neurologic impairment requiring traction equipment.
  2. 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:
• 1. You are confined to a single room, or
  2. You are confined to one level of the home environment and there is no toilet on that level, or
  3. 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:
• 1. 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
  2. You require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
  3. 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
  4. 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.