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Medicare Guidelines Home Medical Equipment Qualifications Mobility - Medical equipment qualifications for Medicare or Medicaid Cane or Crutch criteria Walker criteria Manual Wheelchair criteria Cushions and Backs for Wheelchairs criteria Power Wheelchair & Scooter criteria Seating Sytems Respiratory - Medical equipment qualifications for Medicare or Medicaid Oxygen criteria Nebulizer criteria CPAP criteria BPAP criteria Suction Machine criteria Beds & Patient Lifts - Medical equipment qualifications for Medicare or Medicaid Hospital Beds criteria Trapeze Air Mattresses (see Wound Care) Patient Lift - (Hoyer Lift) criteria Patient Lift - (Stand Up) criteria Wound Care - Medical equipment qualifications for Medicare or Medicaid Cushions - (Wheelchairs) - prevention criteria Bed Surfaces - for skin breakdown prevention and treatment Lymphedema Pumps (compression therapy) criteria Diabetic - Medical equipment qualifications for Medicare or Medicaid Diabetic Shoes and Inserts criteria Diabetic Test strips and lancets criteria Diabetic Gauntlets criteria Diabetic Male Pumps criteria Diabetic Hot/Cold Therapy criteria Lift Chairs & Mechanisms - Medical equipment qualifications for Medicare or Medicaid Lift Chair criteria back to top Mobility ProductsMobility Products: Canes, Walkers, Wheelchairs, and ScootersEssentially the new Mobility Assistive Equipment regulations will ensure that Medicare funds are used to pay for:
back to top Canes and Crutches Medicare Coverage Criteria Canes and crutches are covered when prescribed by a physician for a patient with a condition causing impaired ambulation and MRADL's (mobility related activities of daily living) cannot be accomplished without risk of safety, without being performed in a timely manner or complete inability. This must be documented in Physician, nurse or therapy notes. Required Documentation: Prescription An order for canes and crutches which is reviewed, signed and dated by the ordering physician must be kept on file by the supplier. The medical records must contain information which supports the medical necessity of the item ordered. back to top Walkers Medicare Coverage Criteria Medicare pays for walkers with our without wheels if a patient has
Medicare pays for Rollators up to $130 (keep in mind that Medicare pays 80% of allowable, 20% must be paid by patient or secondary payer). The difference between the cost of the Rollator and Medicare paid amount is patient's responsibility. Please note that if you have received a regular walker from Medicare and now need a Rollator, Medicare will not pay for it because it will be considered same or similar equipment and change in condition will not justify the new equipment. Required Documentation: Prescription An order for the walker which is signed and dated by the treating physician must be kept on file by the supplier. The medical records must contain information which supports the medical necessity of the item ordered. If a rollator is ordered, the usual out of pocket expense does not exceed $40 back to top Manual Wheelchairs Medicare Coverage Criteria Medicare pays for standard/lightweight manual wheelchairs and transport wheelchairs on a capped rental basis. This means that the equipment is rental 13 months and is the property of Vienna Medical and must be returned to us if the patient is no longer in need of the equipment, has moved into a Skilled Nursing Facility or has passed away. After Medicare pays for the 13 months rental, the equipment will become the beneficiaries. If repairs or maintenance is required on patient owned equipment, Medicare may pay for the repairs. Because the equipment is a rental for the initial 13 months, Vienna Medical can only rent within our service area and cannot bill Medicare for manual wheelchairs or transport wheelchairs purchased online. If you live within our rental area please read below for manual wheelchair coverage Required Documentation:
Criteria A, B, C, D, and E are met, and Criterion F or G is met. Additional coverage criteria for specific devices are listed below. 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 such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity. An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds. Coverage of an ultra-lightweight wheelchair (K0005) and manual tilt in space wheelchair (E1161) are determined on an individual consideration basis. Ultra-lightweight wheelchairs and tilt in space wheelchairs are paid for as a purchase because they must be custom ordered based on patient's specifications and needs - pending Advance Determination of Medical Coverage. Patient's medical records can be submitted to Medicare to determine coverage. This can take up to 30 days after the necessary documentation has been provided by the physician and other clinicians. Sport wheelchairs and bathroom wheelchairs are not covered by Medicare. back to top Seat and Back Cushions for Wheelchairs Medicare Coverage Criteria A general use seat cushion and a general use wheelchair back cushion are covered for a patient who has a manual wheelchair. A skin protection seat cushion is covered for a patient who meets both of the following criteria: 1) The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and a) Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or 1) The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; andRequired Documentation: Prescription with DX A headrest is also covered when the patient has a covered manual tilt-in-space wheelchair, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system. A combination skin protection and positioning seat cushion is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. A seat or back cushion that is provided for use with a transport wheelchair (E1037, E1038) will be denied as not medically necessary. back to top Power Wheelchairs and Scooters Medicare Coverage Criteria Remember, the rule here is that there must be very good reasons why a other products won't solve the challenged MRADL (mobility related activities of daily living). For example, if the patient can use a manual wheelchair to solve their affected ADL from the mobility deficit then they do not qualify for a scooter or power chair. Should other products not solve the problem we move to the next step. These are the order of events to qualify a patient for a scooter or pwc.
For a power wheelchair (PWC) or mobility scooter (POV – power operated vehicle ) to be covered, we must receive from the treating physician a written order containing all of the following elements: 1) Beneficiary’s nameThis order must be received by Vienna Medical within 45 days before or after completion of the physician’s face-to-face examination and prior to delivery of the device. (Exception: If the examination is performed during a hospital or nursing home stay, we must receive the order within 45 days after discharge.) Face-to-face examination: For a power wheelchair or mobility scooter to be covered, the treating physician must conduct a face-to-face examination of the patient; Or the physician may write an order for another clinician to perform such as a PT, OT or RN. Then the clinician would perform and submit to the physician for final approval in addition to providing clinical notes documenting the evaluation and any history leading up to the need for the product. The report of the face-to-face examination shall provide information relating to the following questions: • What is this patient’s mobility limitation and how does it interfere with the performance of activities of daily living?The report shall provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation. • SymptomsThe elements that are addressed will depend on the diagnoses that are responsible for the mobility deficit. For example, for patients with COPD, heart failure, or arthritis, the major emphasis will be on symptoms and history of the progression of their condition rather than on the physical examination. Functional assessment is important for all patients. Physicians shall also provide reports of pertinent laboratory tests, x-rays, and/or other diagnostic tests (e.g., pulmonary function tests, cardiac stress test, electromyogram, etc.) performed in the course of management of the patient. Physicians shall document the evaluation in a detailed narrative note in their charts in the format that they use for other entries. The note must clearly indicate that a major reason for the visit was a mobility evaluation. Physician Fee for Face-To-Face evaluation Due to the MMA requirement that the physician or treating practitioner create a written prescription and a regulatory requirement that the physician or treating practitioner prepare pertinent parts of the medical record for submission to the durable medical equipment supplier, the Centers for Medicare & Medicaid Services (CMS) has established the new G Code (G0372) to recognize additional physician services and resources required to establish and document the need for a PMD. CMS believes that the typical amount of additional physician services and resources involved is equivalent to the physician fee schedule relative values established for a level 1 office visit for an established patient (Current Procedural Terminology (CPT) code 99211). The payment amount for such a visit is $21.60 Code G0372 indicates that: - All of the information necessary to document the PMD prescription is included in the medical record. - The prescription, along with the supporting documentation, has been received by the PMD supplier within 45 days after the face-to-face examination. Effective October 25, 2005, G0372, will be used to recognize additional physician services and resources required to establish and document the need for the PMD, and are added to the Medicare physician fee schedule. back to top Seating Systems Medicare Coverage Criteria A custom-fabricated back module for orthotic seating is covered when:
Respiratory Products Oxygen Medicare Coverage Criteria Medicare coverage of home oxygen therapy is available only for patients with significant hypoxemia in the chronic stable state provided the following conditions are met:
Group 1 - Coverage is provided for patients with significant hypoxemia evidenced by any of the following:
back to top Nebulizers Medicare Coverage Criteria Nebulizer machines, medications and related accessories are usually covered for patients with obstructive pulmonary disease, but can also be covered to deliver specific medications to patients with HIV, CF, brochiectasis, pneumocystosis, complications of organ transplants, or for persistent thick or tenacious pulmonary secretions. Patients can obtain up to a three month’s supply of nebulizer medications and accessories at a time. back to top CPAP Medicare Coverage Criteria Continuous Positive Airway Pressure (CPAP) Devices are covered only for patients with obstructive sleep apnea (OSA). You must have an overnight sleep study performed in a sleep laboratory to establish a qualifying diagnosis. Home and mobile sleep labs/studies are not accepted for diagnosing this condition. Medicare will also pay for replacement masks, cannulas, tubing and other necessary supplies. After your first three months of use, 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. Most machines and all of Vienna Medical's CPAP and BPAP machines are compliant report ready. back to top BPAP Medicare Coverage Criteria BiPaps/Respiratory Assist Devices For a respiratory assist device to be covered, the treating physician must fully document in your medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc. A respiratory assist device is covered for those patients with clinical disorder groups 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 (IV) obstructive sleep apnea (OSA). Various tests may need to be performed to establish one of the above diagnosis groups. Three months after starting your therapy, both your physician and you will be required to respond in writing to questions regarding your continued use along with how well the machine is treating your condition. back to top Suction Machines Medicare Coverage Criteria Use of a home model suction pump is covered for recipients who have difficulty raising and clearing secretions secondary to:
back to top Beds & Patient Lifts Hospital Beds Medicare Coverage Criteria A hospital bed is covered if one or more of the following criteria (1-4) are met:
back to top Trapeze & Bed Boards Medicare Coverage Criteria A trapeze bar is covered when a recipient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed. A bed cradle is covered for a recipient with acute gouty arthritis (ICD-9-CM 274.0) or burns (ICD-9-CM 942.00, 943.59, 945.00 or 945.59) for whom it is necessary to prevent contact with the bed coverings. Coverage and Payment Policy An "attachable" trapeze bar is not covered when used on a non- hospital bed. A trapeze bar is covered when it is either an integral part of or used on a hospital bed, and it has been determined that both the hospital bed and the trapeze bar are medically necessary. When "free standing" trapeze equipment is prescribed, it must meet the same criteria as the attached equipment, and the recipient must not be renting or own a hospital bed. Side rails are covered when an integral part of, or an accessory to, a hospital bed if the recipient's condition requires bed side rails. A bed board is not covered, since it is not medical in nature. back to top Air Mattresses - GROUP 1 AND 2 Medicare Coverage Criteria See Wound Care - click here back to top Patient Lifts - Hoyer Medicare Coverage Criteria A lift is covered if transfer between bed and a chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the patient 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 provider Vienna Medical can usually apply the cost of the manual lift toward the purchase price of the electric model by using an Advance Beneficiary Notice (ABN). You would be responsible to pay the difference in the retail charges between the two items. Usually around $40/month. back to top Patient Lifts - Stand Up (Sarah Lifts For Rent) Medicare Coverage Criteria Stand up lifts covered under Hoyer lifts above but there is a difference in monthly out of pocket expense for patients. Please call to inquire. back to top Wound Care Cushions and backs - Wheelchairs Medicare Coverage Criteria See above in Wheelchairs - click here back to top Bed Surfaces - (Group 1 and 2) Medicare Coverage Criteria Group 1 products are designed to be placed on top of a standard hospital or home mattress. They can utilize gel, foam, water or air, and are covered for patients that are: Completely immobile OR Have limited mobility with any stage ulcer on the trunk or pelvis (and one of the following):
Lymphedema Pumps Medicare Coverage Criteria Medicare and major insurance carriers recognize these pumps as safe and effective treatment of: Primary and secondary Lymphedema Post Mastectomy/post lumpectomy/post radiation Lymphedema Venous insufficiency Venous stasis ulcers Prevention of thrombosis Compression pumps are covered for treatment of true Lymphedema as a result of: Primary Lymphedema resulting from a congenital abnormality of lymphatic drainage or Milroy's disease, or Secondary Lymphedema resulting from the destruction of or damage to formerly functioning lymphatic channels such as:
back to top Diabetics Diabetic Shoes & Inserts Medicare Coverage Criteria In an effort to prevent foot ulcers in people with diabetes who are at risk, Medicare will help pay for therapeutic shoes. For those who qualify, Medicare will pay 80 percent of the allowed amount for one pair of shoes and up to three pairs of molded innersoles per year. (The allowed amount varies depending on the kind of footwear you need.) Most secondary insurers will help pay the other 20 percent. Who Qualifies Medicare Diabetic Shoes and Inserts? To qualify, you must be under a comprehensive diabetes treatment plan and have one or more of the following:
back to top Diabetic Test Strips & Lancets Medicare Coverage Criteria Diabetic Supplies
Diabetic Gauntlets Medicare Coverage Criteria The ankle/foot gauntlet was designed to provide stability and elevate the subcutaneous skin temperature to help stimulate circulation and provide protection and comfort. This therapeutic device can increase blood flow and help provide temporary pain relief. One of the following conditions will qualify you for coverage:
Diabetic Impotence Device Medicare Coverage Criteria Impotence Device - The vacuum erection pump offers a drug-free, safe and effective solution to diabetic impotence. It is non-invasive and has no side effects. Vacuum therapy restores adequate blood flow to the penis by creating negative vacuum pressure to create the erection in less than 60 seconds. It is rapidly becoming one of the most popular solutions to erectile dysfunction. If you have one of the following conditions, it may be covered by Medicare:
Diabetic Hot/Cold Therapy Medicare Coverage Criteria Moist heating pads provide treatment that retains moisture from the air. Great for arthritis, it dilates the blood vessels, increasing circulation and creating blood flow. This takes away waste and toxins that may have settled in injured areas and brings new blood cells to the tissue. Must have severe Arthritis pain and meet one of the following criteria:
Lift Chairs & Mechanisms Lift Chairs Medicare Coverage Criteria For lift chairs, Medicare will only cover the seat lift mechanism, but not the actual chair itself. The reimbursement amount is roughly $300 depending on the state in which the patient is located. A lift chair would be considered medically necessary if all of the following coverage criteria are met:
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