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Oxygen Therapy
Oxygen concentrators
Portable cylinders
Oxygen conserving devices

Bathroom Safety
3 to 1 commodes
Transfer benches
Shower chairs
Safety rails
Toilet seat elevetors

Personal Items
Incontinent supplies
Orthopedic Supports
Braces/splints
Compression stockings

Wheelchairs
Standard (adult, youth and pediatric)
Customized Wheelchair accessories
Scooters
Power Chairs
Gel cushions and back cushions

Walking Aides
Crutches
Canes
Walkers
Walkers with seats

Nutritional
Enteral Fedding pumps and supplies
Nutritional Supplements
Suction Machines

Room Furnishings
Hospital Beds
Over-the-bed tables
Hoyer lifts
Trapeze bars
Alternating pressure pads
Alternating pressure mattresses
Lift chairs

Respiratory-Related Equipment
Humidifiers
Nebulizers
Vaporizers

Diabetic Supplies
Glucometers
Test Strips and supplies
Diabetic shoes and inserts

 
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
    • Insomnia
    • Hypertension
    • Ischemic heart disease
    • 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 nebulizers 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: AirSep, 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:

    1. 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.
    2. 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.
    3. 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
  • Dependent edema suggesting CHF, or
  • 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.
  • 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.

 
Electric Scooters or POV

Category of Service: Capped Rental
Available in 3 wheel, 4 wheel or travel models, some major manufacturs 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 patientĀ  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.

 
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 spasticity.

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 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.

 
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 physician's 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.

 
Hospital Beds

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. Medicare coverage criteria:

  • 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 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. Medicare coverage criteria:

  • 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 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. Medicare coverage criteria:

  • 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 positionĀ  and / or has an immediate need for a change in body position.

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:

  • 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, that 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.