FAQ

FAQ's

What is the basic Medicare coverage criteria?

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. MOST INSURANCE PROVIDERS USE THESE REQUIREMENTS.

What is the coverage criteria for a Power Mobility Device?

A Power Mobility Device (scooter or power chair) maybe be covered when all of the following criteria are met and documented by a physician:

Prevents the patient from accomplishing an MRADL entirely, or
Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
Prevents the patient from completing an MRADL within a reasonable time frame.

B) The patient’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.

C) The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.

Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories.

What is the coverage criteria for a Wheelchair?

A) The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

- A mobility limitation is one that:
1) Prevents the patient from accomplishing an MRADL entirely, or
2) Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
3) Prevents the patient from completing an MRADL within a reasonable time frame.

B) The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.

C) The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided

What is the coverage criteria for a Walker?

1) It is prescribed by a physician for a patient with a medical condition impairing ambulation and there is a potential for ambulation; and

2) There is a need for greater stability and security than provided by a cane or crutches.

What is the coverage criteria for a Hospital Bed?

A fixed height hospital bed (E0250, E0251, E0290, and E0291) is covered if one or more of the following criteria 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.

SERVICE WOK

Repairs - To repair means to fix or mend and to put the equipment back in good condition after normal useful wear to make the equipment serviceable.

Insurances does not pay for repair of previously denied equipment
If equipment is in rental, separately itemized charges for repair of rented equipment may be the responsibility of the retailer.
Typically a new Certificate of Medical Necessity (CMN) and/or physician's order is not needed for repairs.

Maintenance - To maintain equipment refers to testing, cleaning, regulating and checking of the equipment.

Such routine maintenance is generally expected to be done by the owner rather than by a retailer.
Thus, hiring a third party to do such work is for the convenience of the beneficiary and is typical not covered by insurances.
However, more extensive maintenance which, based on the manufacturers' recommendations, is to be performed by authorized technicians, may be covered by insurance as repairs for medically necessary equipment which a beneficiary owns. This might include, for example, breaking down sealed components and performing tests which require specialized testing equipment not available to the beneficiary.
Typically a new CMN and/or physician's order is not needed for covered maintenance.

Replacement -Replacement refers to the provision of an identical or nearly identical item.

Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage.
Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood, etc.)
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified which insurances may define as on or about 5 years.
Typically a physician’s order and/or new Certificate of Medical Necessity (CMN), when required, are needed to reaffirm the medical necessity of the item.

*Cases suggesting malicious damage, culpable neglect or wrongful disposition of equipment will be investigated and will be denied by most insurance.

Please feel free to call us with any coverage question you have.

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