Quick Reference
Oxygen, Positive Airway Pressure (PAP) devices and Negative Pressure Wound Therapy (NPWT), and some other items (such as nebulizers, beds, and wheelchairs) require documentation that the patient had an in-person, face-to-face examination by the treating practitioner prior to delivery of the applicable DME item(s).
The record of the face-to-face encounter must document that the beneficiary was evaluated and/or treated for a condition that supports the item ordered.
A specific diagnosis is not required in the medical record/chart notes. However, for equipment for which an in-person, face-to-face examination is required, the documentation requirements are in addition to those documents required in the National Coverage Determination (NCD) or Local Coverage Determination (LCD).
Note
Medicare Local Coverage Determination (LCD) for some products may provide different time frames in which a face-to-face evaluation must be conducted.
If there is a variance between the timeframes defined in the Affordable Care Act and the LCD, the Local Coverage Determinations timeframe should always be used.
Bedside Commodes
- Bedside commodes are only covered if the patient is room-confined or unable to get to toilet facilities. Commodes are not covered if they are placed over the toilet in the bathroom. Medical need must be documented in patient’s medical record.
- Heavy duty commodes: Width equal to or greater than 23 inches and weight capacity 300 pounds or more.
- Detachable arms are covered when used to facilitate transfers or fi the patient has a body configuration that requires extra width. This applies to any commode.
- Supplier must have documentation on file detailing why patient is room-confined or unable to access toilet facilities.
Patient Lifts
- Patient lifts (Hoyer or other types) are covered if transfer between bed and a chair, a wheelchair, or commode requires the assistance of more than one person and, without the use of a life, the patient would be bed confined.
Lift Chairs
- All of the following criteria must be met in order to consider coverage:
- Patient must be able to ambulate once standing (cannot be used in conjunction with a wheelchair or POV).
- Has severe arthritis of hip or knee or severe neuromuscular disease. Diagnosis required.
- Must be a part of the physician’s course of treatment and be prescribed to effect improvement, or arrest or retard deterioration of the patient’s condition.
- Patient must be completely incapable of standing up from any chair in his/her home. 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-life 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.
- Once standing, the patient must have the ability to ambulate.
Support Surfaces
Group 1 (Overlays)
Patient must meet criteria 1, 2, or 3
- Completely immobile – Patient cannot make changes in body position without assistance, OR
- Limited mobility – Patient cannot independently make changes in body position significant enough to alleviate pressure, OR
- Any stage pressure ulcer on the trunk or pelvis.
If the patient meets criteria 2 or 3 above he/she must also have at least one of the following conditions:
- Impaired nutritional status
- Fecal or urinary incontinence
- Altered sensory preception
- Compromised circulatory status
Group 2 (powered pressure-reducing mattresses)
Patient must meet criteria 1 AND 2 OR criterion 3 OR criterion 4 below.
- Multiple stage II pressure ulcers located on trunk or pelvis that have failed to improve over the last month AND
- Patient has been on a comprehensive ulcer treatment program for at least the past month, which has included: the use of an appropriate Group 1 support surface; regular assessment; appropriate turning, positioning and wound care; moisture and incontinence management; and nutritional assessment and intervention.
- Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis OR
- Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) and patient has been on a Group 2 or 3 support surface immediately prior to discharge from the hospital or nursing facility (discharge within the past 30 days).
Group 3 (air-fluidized bed)
Patient must meet ALL of the following.
- Stage III (full-thickness tissue loss) or stage IV (deep tissue destruction) pressure sore.
- Bedridden or chair bound as a result of severely limited mobility.
- In absence of an air-fluidized bed, the patient would require institutionalization.
- The air-fluidized bed is ordered in writing by the patient’s attending physician based upon a comprehensive assessment and evaluation of the patient after conservative treatment has been tried without success. Conservative treatment should generally include: frequent repositioning, use of Group 2; would management; nutritional optimization; education of patient and caregiver on the prevention and/or management of pressure ulcers and ; assessment by physician, nurse, or other licensed health care practitioner at least weekly.
Beds
Fixed-height hospital bed coverage is considered for a when at least one of the following are met:
- Has medical condition which requires positioning of the body in ways not feasible with an ordinary bed.
- Patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain.
- Requires the head of the bed to be elevated more than 30 degrees most of the time because of CHF, COPD, or problems with aspirations.
- Requires traction equipment that can only be attached to a hospital bed.
If a heavy duty-type bed is medically necessary, the weight must be at least 350 pounds and must be documented.
Semi-electric beds are considered for coverage if one of the above criteria is met AND if the patient requires frequent changes in body position such as to alleviate pain, prevent aspiration, or a respiratory issue.
Full electric beds are not covered by Medicare.
Detailed Written Order requirements:
- Beneficiary’s name
- Date of order
- Detailed description of the item being ordered (be specific to the type of bed, for example: fixed height, semi-electric, high/low semi-electric bed, etc)
- Any other items being billed
- Length of need
- Treating practitioner’s printed name and NPI
- Treating practitioner’s signature and signature date
Mobility Equipment
Remember you must rule out each lower level item. Medicare pays for the least costly alternative.
- Cane – Written order and there is a mobility impairment but potential for ambulation.
- Walker – Written order and there is mobility impairment that cannot be corrected with a cane but potential for ambulation. Heavy duty would need weight greater than 300 pounds.
- Specialty Walker (HD – multiple braking system, variable wheel resistance walker) – patient meets criteria for a walker but cannot use standard due to severe neurologic disorder or other condition causing restricted use of one hand (obesity alone is not sufficient reason).
- Manual Wheelchairs – Must rule out use of cane/walker
- Standard – Rule out cane and walker; does not have to be able to self-propel, but needs manual wheelchair for use within the home.
- Hemi-height – Need manual wheelchair; need lower seat to floor height for transfers and/or to assist with self-propelling with feet.
- Lightweight – Rule out cane/walker and standard weight manual wheelchair. MUST be independent in self-propelling with the lightweight wheelchair (cannot be needed solely for caregiver convenience).
- High strength lightweight – Rule out standard, hemi-height and lightweight. Needs a seat width/seat depth/seat-to-floor height no available in ANY lower level base and/or patient is up in chair greater than two hours per day and highly active. Does not have to be self-propelled. Needs could relate to activity level or size of patient (i,e., extremely tall or very short and requires ultra-hemi seat height).
- Ultra Lightweight – As of March 1, 2013, requires AtP and PT/OT evaluation as well as face-face exam by physician and must have past history of use of same type base and activity both inside and outside the home. Patient must be a full-time independent manual wheelchair user and must require individualized fitting and adjustment such as, but not limited to, axle configuration, wheel chamber or seat and back angles that are not available on a lower-level wheelchair. Need to be very specific as to what is needed on this base that is NOT availale on a high-strength lightweight base (K0004).
- Heavy-duty base is covered if patient needs a manual wheelchair and weight is greater than 250 pounds.
- Extra heavy duty is covered if patients needs a manual wheelchairs and weight is greater than 300 pounds.
- A transport chair (E1037, E1038, E1039) is covered in lieu of a standard manual wheelchair for use within the home.
With all manual wheelchairs, the first rule to remember is that the need is for IN THE HOME and must rule out each lower-level item before a higher level is covered.
Detailed Written Order requirements:
- Beneficiary’s name
- Height and weight
- Date of order
- Detailed description of the item being ordered (be specific to the type of mobility equipment, for example: walker with wheels, lightweight manual wheelchair, hemi-height manual wheelchair, heavy duty manual wheelchair, etc.)
- Any other items being billed
- Length of need
- Treating practitioner’s printed name and NPI
- Treating practitioner’s signature and signature date
Non-invasive Ventilators
Non-invasive ventilator treatment is generally covered if treatment is needed for:
- Neuromuscular disorder
- Thoracic disorder diseases
- Chronic respiratory failure associated with a respiratory illness such as chronic obstructive pulmonary disease (COPD)
If patient has had repeated hospital admissions due to respiratory failure, make sure that this information is documented because it will help meet coverage. If a ventilator is used, make sure follow-up visits are documented in the medical record by treating practitioner to show there was a decrease in admissions. Remember Medicare pays for least costly alternative, which means a BiPAP or BiPAP S/T needs to be considered, or tried and ruled out. Clinical documentation must be specific to the individual patient’s needs.
Make sure the documentation is very clear and thorough as to why the patient needs a ventilator versus a respiratory assist device such as a BiPAP or BiPAP S/T. The medical record needs to include documentation that supports the severity of the disease and why the ventilator is the appropriate piece of equipment for the patient.
Monthly rental payments include the payment for supplies and accessories.
Detailed Written Order requirements:
- Beneficiary’s name
- Date of order
- Detailed description of the item being ordered and any other items being billed
- Length of need
- Treating practitioner’s printed name and NPI
- Treating practitioner’s signature and signature date
Group 1
- Patient has a severe lung disease or hypoxia-related symptom that might improve with therapy.
Examples:- COPD, diffuse interstitial lung disease, bronchiectasis, cystic fibrosis.
- Hypoxia-related symptoms suh as pulmonary hypertension, recurring CHF due to chronic cor pulmonale, erythrocytosis, impariemnt of cognitive process, nocturnal restlessness, and morning headache.
- Hypoxemia alone will not be covered. There needs to be an underlying condition causing the hypoxemia.
- Non-covered conditions: angina pectoris in absence of hypoxemia, breathlessness without cor pulmonale or hypoxemia, severe peripheral vascular disease, terminal illnesses that do not affect lungs, pneumonia.
- Blood gas study meets criteria indicated below:
- Method 1: On room air at rest while awake oxygen saturation equal to or less than 88 precent or ABG equal to or less than 55 mm Hg
- Method 2: If during exercise must have the following three tests documented:
- Oxygen saturation on room air at rest – should be above 88%
- Oxygen saturation on room air with exercise – needs to be equal to or less than 88%
- Oxygen saturation on oxygen with exercise – shows improvement with oxygen
- Method 3: During sleep on room air oxygen saturation equal to or less than 88% for at least 5 minutes and does not have to be continuous.
NOTE: If patient qualifies with method 2, then WHOMEVER does the testing must document and provide all three test results described above; otherwise the oxygen will not be covered.
3. Alternative treatment measures, such as inhalers or nebulizer treatments, have been tried or considered, and ruled out or clinically ineffective.
For Group 1, all three items above need to be met.
Group 2
- with PO2 of 56-59 mm Hg or oxygen saturation of 89% at rest, while awake, during sleep for 5 minutes or during exercise as described under Group 1, AND
- Dependent edema suggesting CHF, OR
- Pulmonary HTN or cor pulmonale, determined by measurement of pulmonary artery pressure, echocardiogram, or “P” pulmonale on EKG, OR
- Erythrocythemia with hematocrit greater than 56 percent
For Group 1 and Group 2, there must be evidence of an in-person visit with the treating practitioner performed within 30 days before the initial set-up.
Blood gas study:
- Performed by a physician, qualified provider, or laboratory service that can bill Medicare such as an IDTF, and
- Study must have been performed:
- within 30 days of initial certification while patient is in a chronic stable state, OR
- during an inpatient hospital stay and done within two days prior to discharge date.
- If the testing was performed in an emergency room, then it’s considered an acute situation and would not be considered as acceptable for coverage.
Helpful notes:
- If portable oxygen is being ordered, there needs to be documentation in the medical records indicating the patient is mobile within the home.
- Portable oxygen is considered when the blood gas study is performed while patient is awake or with exercise. At-night use only does not qualify for a portable unit.
- A frequency of use must be indicated, i.e. 2 lpm continuous or 3 lpm at night. PRN, or as needed basis, is not covered at Medicare.
- DMEPOS suppliers are not considered as qualified to perform blood gas studies.
- If patient is under a Part A covered stay payment such as hospital, nursing facility, home health or hospice meets the qualified provider standard. Need to be sure that patient is under a Part A covered payment; if not, then the requirements are not met and qualification would be invalid.
Detailed Written Order (DWO) must contain the following:
- Beneficiary’s name
- Date of order
- Detailed description of the item being ordered.
- Route of administration
- Frequency of use
- Length of need
- Treating practitioner’s printed name and NPI
- Treating practitioner’s signature and date
- The CMN can be the DWO but must contain all the information listed above.
Obstructive sleep apnea with use of home oxygen therapy:
For patients requiring the use of home oxygen with PAP device, both the PAP and oxygen policies must be met. The qualifying blodo gas study must be performed during a titration study at a sleep lab facility making sure the pressure is at an optimal setting. The oximetry study performed during this titration shows oxygen saturation of 88% or less for 5 total minutes (does not have to be continuous). There has to be a reduction in AHI/RDI reduced to less than or equal to an average of 10 events/hours or if the initial AHI/RDI was less than an average of 10 events per hour, then the titration demonstrates further reduction is AHI/RDI.
Recertification:
The following to be obtained with the recert CMN for either Group 1 or Group 2:
- Re-evaluation by treating physician documenting patient is benefiting from the oxygen therapy and has shown improvement.
- Copy of most recent blood gas study (can be from the initial test, if that is the most recent) BUT should not be the normal practice.
GROUP 1 = Required after 12 months of initial certification, which means the re-evaluation must occur within 90 days prior to the date of recertification.
GROUP 2 = Required after 3 months of initial certification, which means the re-evaluation must occur between the 61st-90th day following the initial date.
There are four different clinical groups characterized as follows:
GROUP I: Restrictive Thoracic Disorders
GROUP II: Severe Chronic Obstructive Pulmonary Disease (COPD)
GROUP III: Central Sleep Apnea (CSA) or Complex Sleep Apnea (Comp SA)
GROUP IV: Hypoventilation Syndrome
FOR INITIAL COVERAGE:
GROUP I: Restrictive Thoracic Disorders
- Neuromuscular disease or severe thoracic cage abnormality AND
- One of the following:
- Arterial blood gas PaCO2, while awake and breathing patient’s prescribed FIO2 is greater than 45 mm Hg, OR
- Sleep oximetry demonstrates oxygen saturation less than 88% for more than 5 minutes nocturnal, while breathing prescribed FiO2, OR
- For neuromuscular disease (only)
- Maximal inspiratory pressure less than 60cm H2O OR
- Forced vital capacity less than 50 percent predicted
- COPD does not contribute significantly to patient’s pulmonary function.
GROUP II: Severe COPD
Standard BiPAP without backup (E0470):
- ABG PaCO2, while awake and breathing patient’s prescribed FiO2 greater than 52 mm Hg; AND
- Sleep oximetry demonstrates oxygen saturation of less than or equal to 88% for at least 5 minutes nocturnal, done while breathing at 2 lpm or the patient’s prescribed FiO2 (whichever is higer); AND
- Prior to initiating therapy, sleep apnea and treatment with a continuous positive airway pressure device (CPAP) has been considered and ruled out. (Note: Formal sleep testing is not required if there is sufficient information in the medical record to demonstrate that the beneficiary does not suffer from some form of sleep apnea (Obstructive Sleep Apnea (OSA), CSA and/or Comp SA) as the predominant cause of awake hypercapnia or nocturnal arterial oxygen desaturation).
BiPAP with backup (E0471):
Covered for COPD in following two situations:
Situation 1 – BiPAP with backup started any time after a period of initial use of BiPAP without backup if both A and B are met:
- ABG PaCO2, while awake and breathing beneficiary’s prescribed FiO2, shows that the beneficiary’s PaCO2 worsens greater than or equal to 7 mm Hg compared to original result from #1 above.
- Facility-based PSG demonstrates oxygen saturation less than or equal to 88% for at least 5 minutes nocturnal (minimum recording 2 hours) while using BiPAP without backup that is not caused by obstructive upper airway event.
Situation 2 – BiPAP with backup no sooner than 61 days after initial issue of BiPAP without backup if both A and B are met:
- ABG PaCO2 done while awake and breathing beneficiary’s prescribed FiO2, still remains greater than or equal to 52 mm Hg AND
- Sleep oximetry, while breathing with BiPAP without backup, demonstrates oxygen saturation less than or equal to 88% for at least 5 minutes nocturnal, (minimum recording time of 2 hours) while breathing oxygen at 2 lpm or prescribed FiO2, whichever is higher.
GROUP III: Central Sleep Apnea or Complex Sleep Apnea
Prior to initiating therapy, a complete, facility-based, attended polysomnogram must be performed documenting both A and B
- Diagnosis of central sleep apnea (CSA) or complex sleep apnea (CompSA), AND
- Significant improvement of the sleep-associated hypoventilation with the BiPAP with or without backup while breathing prescribed FiO2
Central sleep apnea (CSA) is defined as:
- An apnea-hypopnea index (AHI) greater than or equal to 5, AND
- The sum total of centra apneas plus central hypopneas is greater than 50% of the total apneas an hypopneas, AND
- A central apnea-central hypopnea index (CAHI) is greater than or equal to 5 per hour, AND
- Presence of at least one of the following:
- Sleepiness
- Difficulty initiating or maintaining sleep, frequent awakenings, or nonrestorative sleep
- Awakening sort of breath
- Snoring
- Witnessed Apneas
- There is no evidence of daytime or nocturnal hypoventilation
Complex sleep apnea (CompSA) is a form of central apnea specifically identified by all of the following:
- With use of a positive airway pressure device without a backup rate (E0601 or E0470), the polysomnogram (PSG) shows a pattern of apneas and hypopneas that demonstrates the presistence or emergence of central apneas or central hypopneas upon exposure to CPAP (E0601) or a bi-level device without backup rate (E0470) device when titrated to the point where obstructive events have been effectively treated (obstructive AHI less than 5 per hour).
- After resolution of the obstructive events, the sum total of central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas; AND
- After resolution of the obstructive events, a central apnea-central hypopnea index (CAHI) greater than or equal to 5 per hour.
- For diagnosis of CSA, the central apnea-central hypopnea index (CAHI) is defined as the average number of episodes of central apnea and central hypopnea per hour of sleep without the use of a positive airway pressure device. For CompSA, the CAHI is determined during the use of a positive airway pressure device after obstructive events have disappeared.
- If the AHI or CAHI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events used to calculate the AHI or CAHI must be at least the number of events that would have been required in a 2-hour period (i.e., greater than or equal to 10 events).
GROUP IV: Hypoventilation Syndrome
BiPAP without backup covered if 1, 2, and either 3 or 4 are met:
- ABG PaCO2, done while awake breathing prescribed FiO2 is greater than or equal to 45 mm Hg.
- Spirometry shows FEVI/FVC greater than or equal to 70%.
- ABG PaCO2, done during sleep or immediately upon awaking breathing prescribed FiO2 shows the beneficiary’s PaCO2 worsened greater than or equal to 7 mm Hg compared to result in criterion 1 above.
- PSG demonstrates oxygen saturation less than or equal to 88% for at least 5 minutes nocturnal (minimum recording time of 2 hours) not caused by obstructive upper airway events.
Equipment Specific Reference
- 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), or
- (III) central sleep apnea (CSA) or Complex Sleep Apnea (CompSA),
- (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.
- BiLevel Devices are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Depending on which product is ordered, your supplier may not be able to deliver this equipment to you without a compliant written order or certificate of medical necessity 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
- 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 devices are covered only if both of the criteria below are met:
- You have a musculoskeletal or neurologic impairment requiring traction equipment.
- The appropriate use of a home cervical traction device has been demonstrated to you and you are able to tolerate the selected device.
- A commode is only covered when you are physically incapable of utilizing regular toilet facilities. For example:
- You are confined to a single room, or
- You are confined to one level of the home environment and there is no toilet on that level, or
- 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.
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 (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 mmay prescribe a different device called a Bi-Level or a Respiratory Assist Device, and Medicare can consider this for coverage as well.
- After the 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. 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 4 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 that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Depending on which product is ordered, your supplier may not be able to deliver this equipment to you without a written order or certificate of medical necessity 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 3-month supply 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.
- 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.
- Diabetics can obtain up to a three month supply of testing materials at a time.
- 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.
- In addition, you must send your supplier evidence of compliant testing (e.g. a testing log or notes from your physician) every six months 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 20, nationally contracted suppliers for all testing supplies delivered to your home.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Your supplier may not be able to deliver your glucometer to you without a written order or certificate of medical necessity 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 3-month supply 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.
- Medicare covers one complete pair of glasses, after the last 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.
- Medicare beneficiaries that have a condition called aphakia (patients who 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.
- A hospital bed is covered if you have visited your doctor or healthcare provider and during an office visit your doctor or healthcare provider documents in your chart that one or more of the following criteria (1-4) are met:
- 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
- You require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
- 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
- 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 a capped rental item, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Depending on which product is ordered, your supplier may not be able to deliver this equipment to you without a written order or certificate of medical necessity 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.
- 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. (This is a relatively uncommon, chronic condition), 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).
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity 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.
- All suppliers of Medicare-covered drugs are required to accept assignment on these items.
- 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.
- 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 your wants)
- 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 which is the least level of equipment needed to help you be mobile within your home to 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 selection.
- The majority of all manual and power wheelchairs are considered capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Depending on which product is ordered, your supplier may not be able to deliver this equipment to you without a written order or certificate of medical necessity 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.
- 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.
- 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.
- Nebulizer machines are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Depending on which product is ordered, your supplier may not be able to deliver this equipment to you without a written order or certificate of medical necessity 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 3-month supply of nebulizer accessories 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.
- 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 are covered when it is necessary to attach the shoe(s) to a 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 are covered for people with a:
- colostomy,
- ileostomy, or
- urostomy
- 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.
- 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 (from an artery). ABG test results are reported in millimeters of mercury (mmHg). 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 (%).
- Group I Criteria: mmHG ≤ 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 for 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 mmHg, 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 3 months of the first test to continue therapy for lifetime or until the need is expected to end.
- Group III Criteria: mmHg ≥ 60 or saturation ≥ 90% is considered to be not medically necessary.
- Group I Criteria: mmHG ≤ 55, or saturation ≤ 88%
- Note on nocturnal oxygen therapy: If you only require the use of oxygen 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 appropriate 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, if you still need the equipment, 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.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Depending on which product is ordered, your supplier may not be able deliver this equipment to you without a written order or certificate of medical necessity 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 therapy requires all or part of the gastrointestinal tract to be missing. Nutritional formulas are delivered through a vein.
- Enteral therapy is covered if you cannot swallow or take food orally. Nutrition must be delivered through a tube directly into the gastrointestinal tract.
- Medicare will not pay for nutritional formulas that are taken orally.
- Specialty nutrition/formulations can be covered if you have unique nutrient 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.
- 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.
- 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 in the retail charges between the two items on a monthly basis.
- Patient lifts are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Depending on which product is ordered, your supplier may not be able deliver this equipment to you without a written order or certificate of medical necessity from your doctor or healthcare provider. Your supplier cannot deliver this product to you without a 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.
- In order for Medicare to pay for a seat lift mechanism, 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.
- Transferring directly into a wheelchair will prevent Medicare from paying for the device.
- Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Your supplier cannot deliver this equipment to you without a written order or certificate of medical necessity from your doctor or healthcare provider. 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.
- Group 1 products are designed to be placed on top of standard hospital bed or home mattresses. 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 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 and followed. 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 and you 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 come visit you to make these assessments.
- 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:
- A stage III or stage IV pressure ulcer, and
- Are bedridden or chair bound as the result of limited mobility, and
- In the absence of an air-fluidized bed 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 equipment.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Your supplier cannot deliver these products to you without a 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 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. Any duration longer than that Medicare will deny as not medically necessary.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Your supplier cannot deliver this product to you without a written order or certificate of medical necessity 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.
- 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.
- Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
- Your supplier cannot deliver this product to you without a 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.
- 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 3 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.
- When at home, you may receive up to a 3-month supply at one time.
- You must have nearly depleted the supplies on hand to be eligible for additional products.