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PRODUCT
EDUCATION
Listed below are the most commonly used Durable Medical Equipment products
along with brief descriptions, Medicare Coverage Criteria and pictures. If you
have any additional questions or concerns regarding these or any other products
or coverage please don't hesitate to contact us.
Electric Scooters or (POV)
Category of Service: Capped Rental
Available in 3 wheel, 4 wheel or travel models, some major manufacturers
include; Pride Mobility, Invacare, Bruno, Shoprider and Pacesaver.
Medicare Coverage Criteria (all must be met):
The patient's
condition is such that without the use of a wheelchair the patient would not be
able to move around in their residence.
The patient is
unable to operate a manual wheelchair.
The patient is
capable of safely operating the controls for the scooter.
The patient can
transfer safely in and out of the scooter, and have adequate trunk stability for
safety.
The physician
who orders the scooter, must be one of the following specialists: Rheumatology,
Physical Medicine, Orthopedic Specialist or Neurology.
Note: Medicare will deny a scooter as not being medically necessary
when it is needed for use outside the home only. A scooter that will be used for
recreation and leisure will be denied as not medically necessary.
Power Wheelchairs
Category of Service: Purchase
Available in a variety of styles ranging from the Standard Style, that are
available in rear wheel, mid wheel, and front wheel drive, however when needing
to transport this model you will need a wheelchair lift or ramp. If you do a lot
of traveling then maybe you need a Folding or Transportable Style, which easily
folds or disassembles, and can easily be transferred in the trunk of a car. You
can also purchase a Heavy Duty Power Wheelchair that can accommodate weights up
to 600 lbs. When needing something special or for Rehab, you can get a Custom
Power Wheelchair that is built specifically for the patient. Some major
manufacturers include; Pride Mobility, Sunrise Medical, Invacare, Golden
Technologies, Shoprider and PaceSaver.
Medicare Coverage Criteria (all must be met):
The patient's
condition is such that without the use of a wheelchair the patient would be bed
or chair confined.
The patient's
condition is such that a power wheelchair will be needed long term (6 months
plus).
The patient
requires the use of a wheelchair in their residence to move around.
The patient is
capable of safely operating the controls of a power wheelchair.
The patient has
severe weakness of the upper extremities due to a neurological, muscular or
cardiopulmonary condition.
The patient is
unable to operate a manual wheelchair.
Note: If Medicare has previously covered the rental of a manual
wheelchair, the manual wheelchair must be returned to the company that supplied
it before Medicare will cover the cost of an electric wheelchair.
Lift Chairs
Category of Service: Purchase
Lift Chairs are available in a wide range of styles, fabrics and colors. You can
choose from 2 position, 3 position or infinite position chairs. Some of the lift
chair manufacturers are Golden Technologies, Pride Mobility and Medi-Lift.
Medicare Coverage Criteria (all must be met):
Medicare will only cover the seat lift mechanism, they will not cover the
chair itself. Reimbursement for the seat lift mechanism is about $300.00,
depending on the state in which the patient lives.
The patient
must have severe arthritis of the hip or knee, or have a severe neuromuscular
disease.
The seat lift
mechanism must be a part of the physicians course of treatment and be prescribed
to effect improvement, or arrest or retard deterioration in the patient's
condition.
The patient
must be completely incapable of standing up from a regular armchair or any chair
in their home.
Once standing,
the patient must have the ability to walk.
By Medicare
standards, the fact that a patient has difficulty or is even incapable of
getting up from a chair, particularly a low chair, is not sufficient
justification for a seat lift mechanism. Almost all patients who are capable of
ambulating can get out of an ordinary chair, if the seat height is appropriate
and the chair has arms.
Note: Medicare requires that the physician ordering the seat lift
mechanism must be the attending physician or a consulting physician for the
disease or condition resulting in the need for a seat lift.
Continuous Positive Airway Pressure System (CPAP)
Category of Service: Capped Rental
CPAP is a non-invasive technique for providing low levels of air pressure from a
flow generator, via a nose mask, through the nares. The purpose is to prevent
the collapse of oropharyngeal walls and the obstruction of airflow during sleep,
which occurs in "obstructive sleep apnea" (OSA). The diagnosis of OSA requires
documentation of at least 30 episodes of apnea, each lasting a minimum of 10
seconds, during 6 - 7 hours of recorded sleep. Some major manufacturers of CPAP
products include; Resmed, Respironics and Devilbiss.
Medicare Coverage Criteria (all must be met):
A single level continuous positive airway pressure (CPAP) device is covered
if the patient has a diagnosis of obstructive sleep apnea (OSA) documented by an
attended, facility-based polysomnogram and meets either of the following
criteria (1 or II):
1.
The AHI is =15 events per hour, or
2.
The AHI is from 5 to 14 events per hour with documented symptoms of:
Excessive
daytime sleepiness, impaired cognition, mood disorders, or insomnia,
or Hypertension, ischemic heart disease, or history of stroke.
The AHI must be calculated based on a minimum of 2 hours of recorded sleep
and must be calculated using actual recorded hours of sleep (i.e. the AHI may
not be an extrapolated or projected calculation).
Note: If a continuous positive airway pressure device is provided and
the criteria above has not been met, it will be denied as not medically
necessary.
For the purpose of this policy, polysomnographic studies must be performed in
a facility based sleep study laboratory, and not in the home or in a mobile
facility. These labs must be qualified providers of Medicare services and comply
with all applicable state regulatory requirements.
To continued coverage beyond the First Three Months of Therapy requires that,
no sooner than the 61st day after initiating therapy, the supplier ascertain
from either the beneficiary or the treating physician that the beneficiary is
continuing to use the CPAP device.
Note: If the above criterion is not met, continued coverage of a CPAP
device and related accessories will be denied as not medically necessary.
Nebulizers
Category of Service: Capped Rental
A nebulizer is an effective method of delivering respiratory medications. It
uses a filtered air compressor to nebulize unit dose medications. Some major
manufacturers of nubulizers include;Devilbiss and Respironics.
Medicare Coverage Criteria (one of the following must be met):
It is medically
necessary to administer beta-adrenergics, anticholinergics, corticosteriods, and
cromolyn for the management of obstructive pulmonary disease.
It is medically
necessary to administer gentamicin, tobramycin, amikacin, or dornase alpha for
cystic fibrosis.
It is medically
necessary to administer pentamidine to patients with HIV or complication of
organ transplant.
It is medically
necessary to administer mucolytics (other than dornase alpha) for persistent or
tenacious pulmonary secretions.
Note: Use of inhalation drugs, other than those listed above, will be
denied as not medically necessary. For criterion (I) to be met, the physician
must have considered use of a metered dose inhaler (MDI) with and without a
reservoir or spacer device and decided that, for medical reasons, it was not
sufficient for the administration of needed inhalation drugs.
Oxygen Therapy
Category of Service: Rental
Oxygen Concentrators
The most common form of oxygen delivery for the home is the concentrator,
which extracts the oxygen from the air and is generally delivered into the body
by nasal cannula (a tube that attaches to the nostrils by a prong). Oxygen
concentrators today are extremely efficient and quiet. However, oxygen
concentrators are not portable and would require a small portable tank to take
with you when you leave. Some major manufacturers of oxygen concentrators
include; Devilbiss, Invacare and Respironics.
Medicare Coverage Criteria (all must be met):
1.
Physician has determined that the patient has severe lung disease or
hypoxia-related symptoms that might be expected to improve with oxygen therapy.
2.
The patient's blood gas study meets the criteria stated below.
3.
The qualifying blood gas study was performed by a physician or by a
qualified provider or supplier of laboratory services.
4.
The qualifying blood gas study was obtained under one of the following
conditions
If the
qualifying blood gas study is performed during an inpatient hospital stay, the
reported test must be one obtained closest to, but no earlier than, 2 days prior
to hospital discharge date.
If the
qualifying test is done without a hospital stay, the reported test must be
performed while the patient is in a chronic stable state.
alternate
treatment measures have been tried and deemed clinically ineffective.
Patient's blood gas levels must fall into the following ranges:
Group I: Coverage Approved
PO2 at or below 55 mm Hg or O2 Saturation at or below 88%:
Taken at rest,
or
Taken during
sleep for a patient who doesn't meet #1 above. Coverage is provided for
nocturnal use only, or
A decrease in
arterial PO2 more than 10mm Hg, or decrease in arterial saturation more than 5%
taken during sleep with symptoms attributable to hypoxemia, or
Taken during
exercise for a patient who doesn't meet #1 above. Oxygen would be covered during
exercise if it is documented that the use of oxygen improves the hypoxemia that
was demonstrated during exercise when the patient was breathing room air
Group II: Not Covered Unless
PO2 is 56 mm Hg to 59 mm Hg or O2 Saturation of 89% and
1.
Dependent edema suggesting CHF, or
2.
pulmonary hypertension or Cor pulmonale, or erythrocythemia with a
hematocrit greater than 56%
Group III: Not Covered
PO2 of 60 mm Hg or O2 saturation of 90% or above:
1.
Coverage is unlikely unless there is detailed documentation submitted to
justify need.
Special Notes:
Supplies (cannulas)
are included in the rental price.
Spare
tanks/backups are not separately reimbursable.
Reimbursement
rate for patients on < 1 LPM is 50% of the Medicare allowable.
Reimbursement
rate for patients on > 4 LPM is 150% of the Medicare allowable.
Reimbursement
rate for patients on > 4 LPM is 150% of the Medicare allowable.
Portable
systems are covered if the patient is mobile within the home.
Note:
The qualifying blood gas study must be performed by a physician or by a
qualified Medicare Part A provider or a qualified laboratory. A supplier is not
considered a qualified provider or a qualified laboratory for purposes of this
policy. In addition, the qualifying blood gas study may not be paid for by any
supplier. This does not extend to blood gas studies performed by a hospital
certified to do such tests.
Wheelchairs
Category of Service: Capped Rental
Wheelchairs are available in a wide variety of sizes and styles, never
purchase a wheelchair without being properly fitted, not only for the width, but
the footrest height as well.
Wheelchair Types
Standard Wheelchairs - K0001
Basic
wheelchair is available with full length fixed armrests or detachable desk
length arms. Desk length arms are designed to fit underneath a table or desk, it
allows the patient to maintain a close distance to the table.
Hemi Wheelchair - K0002
The hemi
wheelchair is medically necessary for patients who need to have their seat lower
to the ground due to their short stature, or to enable the patient to place
their feet on the ground to propel themselves. Note: Most Wheelchairs
today have both a standard and hemi axle to accommodate most patient heights.
The hemi wheelchair is also available with either fixed full length or
detachable desk length arms.
Lightweight Wheelchair - K0003
A lightweight
wheelchair is medically necessary when a patient cannot propel themselves in a
standard wheelchair, but is able in a lightweight wheelchair. Note: A
lightweight wheelchair is not covered because a caregiver has difficulty lifting
(due to weight) a standard wheelchair.
High Strength Lightweight Wheelchair - K0004
A high strength
lightweight wheelchair is medically necessary when the patient self propels the
wheelchair while engaging in frequent activities that can not be preformed in a
standard or lightweight wheelchair and/or
The patient
requires a seat width, depth or height that can not be accommodated in a
standard, lightweight or hemi-wheelchair, and spends at least two hours per day
in a wheelchair.
Heavy Duty Wheelchair - K0006
A heavy duty
wheelchair is medically necessary if the patient weighs in excess of 250 lbs. or
the patient has severe spasisticity.
Extra Heavy Duty Wheelchair - K0007
A extra heavy
duty wheelchair is medically necessary if the patient weighs in excess of 300
lbs.
Medicare Coverage Criteria
Wheelchairs are covered and considered medically necessary if the patient would
be chair or bed confined. Please review the criteria specific to each style of
wheelchair above.
Note: Leg Riggings
Swingaway Footrest
Swing to the side of the chair to allow for easy access in and out of the chair,
and are also height adjustable to fit the patients height.
Elevating Legrest
Allows for elevation of the lower extremities, and has a padded calf support,
also height adjustable.
Hospital Bed
Category of Service - Capped Rental
Hospital beds, as they are so commonly referred as; are not only used in
hospitals, but are used in ACLF's and the home care settings as well. There are
three distinct types of hospital beds; manual, semi-electric and full electric.
Some major manufacturers of hospital beds include Sunrise Medical, Invacare and
Drive Medical.
Hospital Bed Types
Manual Beds (Fixed Height)
Manual beds
enable you to raise and lower the head of the bed, along with your knees through
the use of a hand crank.
Manual Beds (Variable Height)
This is the
same as the fixed height manual bed, only it has a hand crank to manually raise
and lower the bed.
Semi-Electric Beds
This is the
most common bed used in the home care setting. The head of the bed as well as
the knees are raised and lowered with an electric hand-held control. The height
of the bed is raised and lowered with the use of a manual hand crank.
Full-Electric Beds
This bed
enables you to not only raise your head and knees with an electric hand-held
control, but the height of the bed also.
Medicare Coverage Criteria
Manual Bed (Fixed Height)
A fixed height
bed is covered if one or more of the following indications are met:
A patient who
requires positioning of the body in ways not feasible with an ordinary bed in
order to alleviate pain.
A patient who
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 tried and failed to achieve the
desired clinical outcome.
A patient who
requires traction equipment which can only be attached to a hospital bed.
Manual Bed (Variable Height)
A patient
qualifies for a variable height hospital bed when the criteria for a fixed
hospital bed is met and
the patient
requires a bed height different than a fixed height hospital bed to permit
transfers to chair, wheelchair or standing position.
Semi-Electric Hospital Bed
A patient
qualifies for a semi-electric hospital bed when the criteria for a fixed height
hospital bed is met and
the patient
requires frequent changes in body position and / or has an immediate need for a
change in body position.
Full Electric Hospital Bed
A full electric
hospital bed is not covered by Medicare, it is viewed as a convenience feature.
Bedside Commodes
Category of Service - Purchase
A bedside commode is a transportable toilet that does not use or need running
water. It looks like a frame with a toilet seat and has a removable pail
underneath. The normally "slides out" for cleaning after use. There are various
types of bedside commodes; there is a "drop arm commode" for easy patient
transfer. A "heavy-duty commode" for those patients that need support up to 400
lbs, and a "3-in-1 commode", which can be used as a raised toilet seat, bedside
commode or a toilet safety frame.
Medicare Coverage Criteria
A bedside commode is covered when the patient is bed or room confined and
incapable of utilizing their regular toilet facilities.
Note: The term "room confined" means that the patient's condition is
such that they are unable to leave the room.
Walkers
Category of Service - Purchase
Walkers are available in a variety styles and sizes to meet everybody's
needs, from folding, hemi or wheeled walkers. Hemi style walkers are good when
utilizing one hand, folding walkers are easy to transport. most fold to a width
of about four inches. Walkers with wheels are good for patients who are unable
to lift the walker when ambulating.
Medicare Coverage Criteria
A walker is covered only when both of the criteria is met:
When prescribed
by a physician for a patient with a medical condition impairing ambulation and
there is a potential for ambulation; and
When there is a
need for greater stability and security than provided by a cane or crutches
Note: Heavy duty, multiple braking system, variable wheel resistance
walkers (rollator walker) is covered for patients who are unable to use a
standard walker due to obesity, severe neurological disorders, or restricted use
of one hand.
Walking Canes
Category of Service - Purchase
Walking canes are available in a variety of styles and handle configurations
to fit most any patient's hand comfortably. Canes are available in an adjustable
height aluminum or non adjustable wood. You would use a cane for added stability
while walking. Quad canes are used when the patient needs more stability than a
"normal stick type cane" would offer. Quad canes are available with either a
small base or large base, the base is made up of four small legs.
Medicare Coverage Criteria
Canes are covered by Medicare when prescribed by a physician for a patient
with a condition causing impaired ambulation; and there is a potential for
ambulation.
Diabetic Monitors & Supplies
Category of Service - Purchase
Medicare covers the same supplies for people with diabetes whether or not
they use insulin. These include glucose testing monitors, blood glucose test
strips, lancet devices and lancets, and glucose control solutions.
HCPCS Codes
E0607 Blood
Glucose Monitor
E2100 Blood
Glucose Monitor integrated voice
E2101 Blood
Glucose Monitors with integrated lancing/blood sample collection
A4253 Blood
Glucose Test Strip
A4259 Lancets
Medicare Coverage Criteria
In order for the patient to obtain coverage, the following criteria must
be met:
Patient has
diabetes which is being treated by a physician, and
The glucose
monitor and related accessories and supplies have been ordered by the physician
who is treating the patient's diabetes, and
The device is
designed for home, not clinical, use, and
The patient (or
caregiver) has been trained and is capable of using test results, and
The patient (or
caregiver) is capable of using the test results.
Note: In addition to the above conditions being met, a blood glucose
monitor with special features (voice synthesizers, automatic timers) is covered
if:
Patient's physician indicates that the patient has visual impairment severe
enough (20/200 or worse) to require use of this special system.
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