Often times, we ask ourselves if we should go through our health insurance vs purchasing items out-of-pocket. The majority of us of course would prefer not to pay for those items if we don’t have to.
However, Medicare (and all the Managed Medicare plans) have very specific criteria for each item that is being submitted for an authorization.
Medical Necessity and Medicare Guidelines
When trying to obtain medical equipment coverage, we will need to keep in mind that to qualify for a durable medical equipment you must meet Medicare medical necessity guidelines. Each medical equipment has specific requirements from Medicare.
For instance, you may feel that due to your grandmother’s advanced age, Medicare should cover a hospital bed for her. However, Medicare (part B) might not cover the same if your grandmother does not have a serious health condition that would require her to be elevated during sleeping.
Let your physician, or hospital staff work with your insurance providers to determine if you would qualify for those specific medical devices for home.
Your doctor’s prescription for medical equipment-What Do You Need to Know?
If you received a doctor’s prescription for let’s say a wheelchair you will need to see if it has a diagnosis code, and your physician NPI number. Also, using just the single word “wheelchair” in the prescription will not help. Instead, it will need to say “Standard Manual Wheelchair” and it needs to have an ICD 10 Code.
If you managed to obtain a specific prescription for durable medical equipment with the above information, then contact Medicare phone number from the back of your insurance card and ask for a list of durable medical equipment- approved medicare suppliers.
If you did not get a prescription with the above two requirements (a detailed order & diagnosis code) it is highly unlikely that Medicare will pay for it.
You probably will ask the Medicare representative via phone if the prescription you received would approve your medical supply.
However, the answer you get from the representative might not necessarily be the same answer of the approval response. Often times, I hear patients stating “my insurance said it is covered” when it hasn’t even been submitted for authorization.
I have to be the one who would probably bring the bad news when patient’s insurance, for numerous reasons, declined coverage for their medical equipment.
In spite of, do not get discouraged; I believe patients should always try their insurance first before considering out-of-pocket expenses.
If you tried all the above, and your insurance still declines the approval, then it’s time you consider purchasing the medical equipment, especially if you feel you still need it.
Procedures and Health Conditions that currently meet medical necessity and Medicare Criteria-for the medical equipment
At this time, Medicare part B, and most managed Medicare plans offer coverage with or without copay to the following:
1. Total Hip Replacements- front wheel walker, and 3:1 commode
2. Total Knee Replacements-Front Wheel Walker, and 3:1 commode
3. Total Ankle Replacements-Standard Manual Wheelchair with elevated leg lift. A knee scooter might be recommended, but is not covered by Medicare.
4. Spinal Fusion-Front Wheel Walker, and 3:1 commode-when recommended by therapist
5. Osteoarthritis of the hip, and/or knee-Front Wheel Walker, 3:1 commode
These are just a few of the numerous health conditions that would meet medical necessity. Keep in mind these are always changing; and also sometimes insurance might still deny coverage for various reasons.
Medicare is almost always changing
Let’s say five years ago you were denied coverage for a specific item for a specific reason. Then, five years later, you have the same medical reason, and your item was approved for coverage. The exact opposite can also happen.
Consider Medicare guidelines, and that their rules are always changing. Lately, their medical criteria has more requirements than in the past. However, when working with your health insurance, try not to judge based on your previous experiences, because often times, the process you were familiar with is obsolete.
If you were denied authorization for a medical equipment, make sure you ask the reason. It might be an error that you are able to fix.
Otherwise, it might even be due that you were approved for the same item in less than five years ago. In this case, even when you no longer have the item, Medicare will not cover the item until five years have passed.
Let the experts handle the referrals, and approval process. Also,maintain communication, it is almost always perfectly fine to help by calling your insurance about the status of an authorization. You are probably accelerating their decision by just one phone call.
If you have any questions or concerns, feel free to leave a comment below, or send me an email at firstname.lastname@example.org.