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CGS Administrators, LLC

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Medicare and My Durable Medical Equipment

Medicare coverage is based on benefit categories set up by Congress. Occasionally, Congress makes a new benefit like in 2003 when they approved the addition of prescription drugs for coverage by Medicare. Medicare does not always pay, or pay in full, for the durable medical equipment item or service you receive. Payment considerations are based on federal regulations and policies in addition to what are called "policy articles" and other technical instructions issued by the Centers for Medicare & Medicaid Services (CMS) and its contractors like CGS. Patient eligibility is also a factor based on the specific requirements outlined in each equipment/service policy. Policies provide, in very specific detail, requirements which must be met before Medicare will consider payment. In some cases, items/services are "statutorily noncovered" which means that under current policy, some items or services will never be paid by Medicare because the law set up by Congress doesn't include that benefit. In some cases, payment will be considered only if the patient meets specific health care-related criteria. That criteria is different for each policy.

If you are looking for payment information, or trying to find out why your claim did not pay, you must call 1.800.MEDICARE. They are the only Medicare contractor with that information. No other contractor, including Jurisdiction C has access to this information.

Posted: 05.28.15

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