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Policy Summaries (Local Coverage Determinations)

Below is a partial list of local coverage determinations or LCDs. Clicking on a title will provide you with a very high level summary of the policy.  The summaries were reviewed by Dr. Robert Hoover, Jr., MD, MPH, FACP. Dr. Hoover is the Chief Medical Officer for CGS DME MAC Jurisdiction C. None of the summaries will contain all of the requirements your medical equipment supplier must follow. A complete list of all policies and requirements is only available on the CMS.gov website. You are welcome to review the official policies however; it is very important that you understand two things:

  1. LCD documents were written specifically for durable medical equipment suppliers and physicians who prescribe durable medical equipment. You may find them difficult to fully understand.
  2. You will be viewing the policies on the CMS website and not the CGS website. CGS does not publish policies to our website. If you are taking the website survey, this is very important to remember. CMS has their own survey and any concerns you have regarding their website should be included in their survey.

Here are the supplier policies for some of the most commonly prescribed durable medical equipment items/services.

PAP (Positive Airway Pressure) and CPAP (Continuous Positive Airway Pressure) Devices

Basic Description: A method of positive pressure ventilation used with patients to keep the alveoli open at the end of exhalation, increasing oxygenation and reducing the work of breathing.

SUMMARY: Positive airway pressure devices are covered under the Durable Medical Equipment benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that positive airway pressure devices are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire PAP policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

As you review this information, Note the use of the words "and" and "or". This is very important! If a policy states that you must have "this" AND "that" – then you must have both. If a policy states you need "this" OR "that" – you may only need one or the other to meet the requirements.

For purposes of this overview, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (CPAP) and a bi-level respiratory assist device (BiPAP) without back-up rate when it is used in the treatment of obstructive sleep apnea.

  1. A CPAP device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:
    1. The beneficiary has a face-to-face clinical evaluation by the treating practioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.
    2. The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):
      1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
      2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
        1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
        2. Hypertension, ischemic heart disease, or history of stroke.
    3. The beneficiary and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for a CPAP is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.

  1. A respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask  device is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to criterion D:
    1. A CPAP has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.

Ineffective is defined as documented failure to meet therapeutic goals using a CPAP during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).

If a respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask is billed for a beneficiary with OSA and criteria A-D are not met, it will be denied as not reasonable and necessary.

A bi-level positive airway pressure device with back-up rate is not reasonable and necessary if the primary diagnosis is OSA. If a respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask is billed with a diagnosis of OSA, it will be denied as not reasonable and necessary.

Important note: Since the patient's condition determines the type of tests and treatment options needed, we can only provide you with a very, very high level overview. Your physician can answer more complex questions regarding positive airway pressure. As a reminder, if you choose to view the entire policy written for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand.

Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case,the durable medical equipment benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Therapeutic Shoes for Persons with Diabetes (Diabetic shoes)

Basic Definition: sometimes referred to as extra depth, therapeutic shoes, or "diabetic shoes". These are specially designed shoes, or shoe inserts, intended to reduce the risk of skin breakdown in diabetics with co-existing foot disease.

SUMMARY: Therapeutic Shoes and inserts are covered under the Therapeutic Shoes for Individuals with Diabetes benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that therapeutic shoes and inserts are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire Therapeutic Shoes for Persons with Diabetes policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

As you review this information, Note the use of the words "and" and "or". This is very important! If a policy states that you must have "this" AND "that" – then you must have both. If a policy states you need "this" OR "that" – you may only need one or the other to meet the requirements.

Therapeutic shoes, inserts and/or modifications to therapeutic shoes are covered if all of the following criteria are met:

  1. The beneficiary has diabetes mellitus; and
  1. The certifying physician has documented in the beneficiary's medical record one or more of the following conditions:
    1. Previous amputation of the other foot, or part of either foot, or
    2. History of previous foot ulceration of either foot, or
    3. History of pre-ulcerative calluses of either foot, or
    4. Peripheral neuropathy with evidence of callus formation of either foot, or
    5. Foot deformity of either foot, or
    6. Poor circulation in either foot; and
  2. The certifying physician has certified that indications (1) and (2) are met and that he/she is treating the beneficiary under a comprehensive plan of care for his/her diabetes and that the beneficiary needs diabetic shoes. For claims with dates of service on or after 01/01/2011, the certifying physician must:
    • Have an in-person visit with the beneficiary during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and
    • Sign the certification statement on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.

Under this policy, if criteria 1-5 are not met, the therapeutic shoes, inserts and/or modifications will be denied as noncovered.

In order to meet criterion 2, the certifying physician must either:

  1. Personally document one or more of criteria a – f in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement; or
  2. Obtain, initial, date (prior to signing the certification statement), and indicate agreement with information from the medical records of an in-person visit with a podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that documents one of more of criteria a – f.

Separate inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes verifies in writing that the beneficiary has appropriate footwear into which the insert can be placed. This footwear must meet the definitions found in this policy for depth shoes or custom-molded shoes.

A custom molded shoe is covered when the beneficiary has a foot deformity that cannot be accommodated by a depth shoe. The nature and severity of the deformity must be well documented in the supplier's records and available upon request. If a custom molded shoe is provided but the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary.

Here are the definitions for the various types of "physicians" referenced in this policy:

The Certifying Physician is defined as a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.) who is responsible for diagnosing and treating the beneficiary's diabetic systemic condition through a comprehensive plan of care. The certifying physician may not be a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist.

The Prescribing Practitioner is the person who actually writes the order for the therapeutic shoe, modifications and inserts. This practitioner must be knowledgeable in the fitting of diabetic shoes and inserts. The prescribing practitioner may be a podiatrist, M.D., D.O., physician assistant, nurse practitioner, or clinical nurse specialist. The prescribing practitioner may be the supplier (i.e., the one who furnishes the footwear).

The "Supplier" is the person or entity that actually furnishes the shoe, modification, and/or insert to the beneficiary and that bills Medicare. The supplier may be a podiatrist, pedorthist, orthotist, prosthetist or other qualified individual. The Prescribing Practitioner may be the supplier. The Certifying Physician may only be the supplier if the certifying physician is practicing in a defined rural area or a defined health professional shortage area.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the therapeutic shoes for persons with diabetes category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Hospital Beds

Basic Definition: A bed used for patients (as in a hospital) that can be adjusted especially to raise the head end, foot end, or middle as required. It is important to note that consumer-type adjustable beds (e.g., Craftmatic®, Tempur-Pedic®) are not payable by Medicare because they do not meet the requirements of the durable medical equipment benefit category.

SUMMARY:Hospital Beds are covered under the Durable Medical Equipment benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that hospital beds are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire Hospital Beds and Accessories policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

As you review this information, Note the use of the words "and" and "or". This is very important! If a policy states that you must have "this" AND "that" – then you must have both. If a policy states you need "this" OR "that" – you may only need one or the other to meet the requirements.

If the beneficiary does not meet any of the coverage criteria for any type of hospital bed it will be denied as not reasonable and necessary.

There are six (6) different types of hospital beds which may be considered for payment by Medicare. We have listed each bed below and we have offered a very general description for each bed:

Fixed Height Hospital Bed: This bed is covered if one or more of the following criteria (1-4) are met:

  1. The beneficiary has 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
  2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
  3. The beneficiary 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, or
  4. The beneficiary requires traction equipment, which can only be attached to a hospital bed.

Variable Height Hospital Bed:This bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

Semi-electric Hospital Bed: This bed is covered if the beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.

Heavy Duty Extra Wide Hospital Bed: This bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.

Extra Heavy Duty Hospital Bed: This bed is covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds.

Total Electric Hospital Bed: This bed is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.

Some accessories for hospital beds may also be covered. Those accessories and their coverage requirements are listed below:

Trapeze equipment is covered if the beneficiary 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.

Heavy duty trapeze equipment is covered if the beneficiary meets the criteria for regular trapeze equipment and the beneficiary's weight is more than 250 pounds.

A bed cradle is covered when it is necessary to prevent contact with the bed coverings.

Side rails or safety enclosures are covered when they are required by the beneficiary's condition and they are an integral part of, or an accessory to, a covered hospital bed.

If a beneficiary's condition requires a replacement innerspring mattressor foam rubber mattress it will be covered for a beneficiary owned hospital bed.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the durable medical equipment benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Nebulizer

Basic Definition: A device used to reduce liquid to an extremely fine cloud, especially for delivering medication to the deep part of the respiratory tract.

SUMMARY: Nebulizers are covered under the Durable Medical Equipment benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that nebulizers are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

There a various types of nebulizers available to Medicare beneficiaries. The type of nebulizer as well as the types and amounts of drugs administered by the nebulizer are determined by your physician. Since the patient's condition determines the type of nebulizer needed as well as they types and amounts of drugs necessary for treatment, we can only provide you with a very high level overview. Your physician can answer more complex questions regarding nebulizers. If you choose to view the entire Nebulizers policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand.   Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

As you review this information, Note the use of the words "and" and "or". This is very important! If a policy states that you must have "this" AND "that" – then you must have both. If a policy states you need "this" OR "that" – you may only need one or the other to meet the requirements.

Depending upon your specific condition, your physician may have prescribed one of the following nebulizers:

A small volume nebulizer, related compressor and FDA-approved inhalation solutions of the drugs listed below are covered when:

  1. It is reasonable and necessary to administer albuterol, arformoterol, budesonide, cromolyn, formoterol, ipratropium, levalbuterol, or metaproterenol for the management of obstructive pulmonary disease; or
  2. It is reasonable and necessary to administer dornase alpha to a beneficiary with cystic fibrosis; or
  3. It is reasonable and necessary to administer tobramycin to a beneficiary with cystic fibrosis or bronchiectasis; or
  4. It is reasonable and necessary to administer pentamidine to a beneficiary with HIV, pneumocystosis, or complications of organ transplants; or
  5. It is reasonable and necessary to administer acetylcysteine for persistent thick or tenacious pulmonary secretions

A large volume nebulizer, related compressor, and water or saline are covered when it is reasonable and necessary to deliver humidity to a beneficiary with thick, tenacious secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a tracheobronchial stent.

A compressor and filtered nebulizer are also covered when it is reasonable and necessary to administer pentamidine to beneficiaries with HIV, pneumocystosis, or complications of organ transplants.

A small volume ultrasonic nebulizer and related accessories are reasonable and necessary to administer treprostinil inhalation solution only.

A controlled dose inhalation drug delivery system is covered when it is reasonable and necessary to deliver iloprost to beneficiaries with pulmonary hypertension only.

A large volume ultrasonic nebulizer offers no proven clinical advantage over a pneumatic compressor and nebulizer and will be denied as not reasonable and necessary.

Due to the complexity and variety of drugs and dosages used for nebulizers, we cannot provide specific coverage information. The type of drug used and the amount you need is determined by your physician. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

REFILL REQUIREMENTS

Suppliers must contact you prior to dispensing a refill. They are not permitted to ship refills on a pre-determined basis, even if you have authorized it. This is done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes/modifications to the order.

Your supplier must not dispense a quantity of supplies exceeding a your expected utilization. Regardless of utilization, a supplier must not dispense more than a three (3)-month quantity at a time.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the durable medical equipment benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Ostomy Supplies

Basic Definition: These are supplies necessary following a surgical procedure creating an opening in the body for the discharge of body wastes.

SUMMARY:Ostomy supplies are covered under the Prosthetic Device benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that ostomy supplies are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire Ostomy Supplies policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

The three most common types of ostomies are:

The quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation according to individual beneficiary need and their needs may vary over time. The actual quantity of supplies needed for a particular beneficiary may vary depending on the factors that affect the frequency of barrier and pouch change.

When a liquid barrier is necessary, either liquid or spray or individual wipes or swabs are appropriate. The use of both is not reasonable and necessary.

Beneficiaries with continent stomas may use the following means to prevent/manage drainage:

No more than one of these types of supply would be reasonable and necessary on a given day.

Beneficiaries with urinary ostomies may use either a bag or bottle for drainage at night. It is not reasonable and necessary to have both.

BARRIERS:

A solid barrier (wafer) is an interface between the beneficiary's skin and the pouching system, has measurable thickness and has an adhesive property. Barriers may be integrated into a "1 piece" pouch, they may be manufactured with a flange and be part of a "2 piece" pouch system (skin barrier with flange), or they may be used independently, usually with a pouch that does not have its own integral skin barrier. An extended wear barrier is a pectin-based barrier with special additives which achieve a stronger adhesive seal, resist breakdown by urine or bowel effluent, permit longer wear times between changes, and normal wear times for those who cannot achieve them with standard barriers.

A barrier with built-in convexity is one in which an outward curve is usually achieved with plastic embedded in the barrier, allowing better protrusion of the stoma and adherence to the skin.

Ostomy skin barriers greater than 4x4 inches refer to the size of the skin barriers themselves, and not to the area of any surrounding tape.

FACEPLATES:
A faceplate is a solid interface between the beneficiary's skin and the pouch. It is usually made of plastic, rubber or encased metal. It does not have an adhesive property and there is no pectin-based or karaya material that is an integral part of a faceplate. It can be taken off the skin and reattached repeatedly. It is secured by means of a separate adhesive and/or an elastic belt. The clips for attaching the belt are usually a part of the faceplate.

POUCHES:
A pouch is a device for collecting stomal output. A pouch for collecting bowel effluent may be either "drainable" with an opening at the bottom through which the fecal contents are emptied, or ‘closed' with a sealed bottom and no outlet. A "urinary" pouch normally incorporates anti-reflux devices and a tap or spigot to empty the urine contents.

A pouch "with barrier attached" is one type of "1 piece" system in which a solid barrier is part of the pouch. There are distinct codes for 1-piece pouches with convex barriers and extended wear barriers.

A pouch "without barrier attached" is a pouch with or without a thin adhesive coating that is applied either directly to the skin or to a separate barrier. It is also described as a "1 piece" system.

A pouch, which is part of a "2 piece" system, has a flange, which enables it to be coupled to a skin barrier with flange.

A pouch "with faceplate attached" or "for use on a faceplate" is generally rubber or heavy plastic. It is drainable, cleanable, and reusable for periods of weeks to months, depending on the product.

A "high output" pouch has a capacity of greater than or equal to 0.75 liters, is drainable with a large bore solid spout with cap or plug, and is either part of a 2 piece system or a single-piece system.

Absorbent material that is added to the ostomy pouch may come as sheets, pads or crystals.

An ostomy pouch with faucet-type tap with valve has a valve for draining urine.

A locking flange is a lever type flange locking mechanism. It differs from simple push-on pouch securing mechanisms. The mechanism may be incorporated either in the pouch flange or skin barrier flange (2 piece system).

PASTES:
A paste is used as a protective layer and sealant beneath ostomy appliances, and is applied directly on the skin. It may be primarily pectin based or non-pectin based, e.g., karaya.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the prosthetic device benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Oxygen and Oxygen Equipment

Basic Definition: Portable or stationary equipment that delivers oxygen to a patient based on a physician's prescription for treatment.

SUMMARY: Oxygen and oxygen equipment is covered under the Durable Medical Equipment benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that oxygen supplies are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire Oxygen and Oxygen Equipment policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

As you review this information, Note the use of the words "and" and "or". This is very important! If a policy states that you must have "this" AND "that" – then you must have both. If a policy states you need "this" OR "that" – you may only need one or the other to meet the requirements.

Home oxygen is covered only when both the reasonable and necessary criteria discussed below and the statutory criteria are met. Home oxygen therapy is reasonable and necessary only if all of the following conditions are met:

  1. The treating physician has determined that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and
  2. The beneficiary's blood gas study meets the criteria stated below, and
  3. The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and
  4. The qualifying blood gas study was obtained under the following conditions:
    • If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or
    • If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, and
  5. Alternative treatment measures have been tried or considered and deemed clinically ineffective.

In this policy, the term blood gas study refers to either an oximetry test or an arterial blood gas test.

Group I criteria include any of the following:

  1. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or
  2. An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a beneficiary who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake, or
  3. A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent from baseline saturation, for at least 5 minutes taken during sleep associated with symptoms (e.g., impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to hypoxemia, or
  4. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a beneficiary who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the beneficiary was breathing room air.

Initial coverage for beneficiaries meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter.

Group II criteria include the presence of

  1. An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria), and
  2. Any of the following:
    1. Dependent edema suggesting congestive heart failure, or
    2. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
    3. Erythrocythemia with a hematocrit greater than 56 percent.

Initial coverage for beneficiaries meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. Group III includes beneficiaries with arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent.

If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not reasonable and necessary. Oxygen therapy will also be denied as not reasonable and necessary if any of the following conditions are present:

  1. Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood and there are other preferred treatments.
  2. Dyspnea without cor pulmonale or evidence of hypoxemia
  3. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation.
  4. Terminal illnesses that do not affect the respiratory system

The Oxygen and Oxygen policy contains very specific and complex instructions based on the type(s) of equipment prescribed as well as patient testing requirements. What we have provided is a very high level summary of basic requirements.

As a reminder, if you choose to view the entire policy written for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the durable medical equipment benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Power Mobility Devices

Basic Definition: For purposes of this educational information, the term power mobility device (PMD) includes power operated vehicles (POVs) and power wheelchairs (PWCs)

SUMMARY: Power mobility devices are covered under the Durable Medical Equipment benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that power mobility devices are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire Power Mobility Devices policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

As you review this information, Note the use of the words "and" and "or". This is very important! If a policy states that you must have "this" AND "that" – then you must have both. If a policy states you need "this" OR "that" – you may only need one or the other to meet the requirements.

Power Mobility Device

All of the following basic criteria (A-C) must be metfor a power mobility device or a push-rim activated power assist device to be covered. Additional coverage criteria for specific devices are listed below.

  1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
    • Prevents the beneficiary from accomplishing an MRADL entirely, or
    • Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
    • Prevents the beneficiary from completing an MRADL within a reasonable time frame.
  2. The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.
  3. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.
    • Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
    • An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories.

POWER OPERATED VEHICLES:

A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met.

  1. The beneficiary is able to:
    • Safely transfer to and from a POV, and
    • Operate the tiller steering system, and
    • Maintain postural stability and position while operating the POV in the home.
  2. The beneficiary's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home.
  3. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided.
  4. The beneficiary's weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV – i.e., a Heavy Duty POV is covered for a beneficiary weighing 285 – 450 pounds; a Very Heavy Duty POV is covered for a beneficiary weighing 428 – 600 pounds.
  5. Use of a POV will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home.
  6. The beneficiary has not expressed an unwillingness to use a POV in the home.

If a POV will be used inside the home and coverage criteria A-I are not met, it will be denied as not reasonable and necessary.

If any POV or PWC is only for use outside the home, it will be denied as noncovered.

POWER WHEELCHAIRS:

A power wheelchair is covered if:

  1. All of the basic coverage criteria (A-C) are met; and
  2. The beneficiary does not meet coverage criterion D, E, or F for a POV; and
  3. Either criterion J or K is met; and
  4. Criteria L, M, N, and O are met; and
  5. Any coverage criteria pertaining to the specific wheelchair type (see below) are met.
  6. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided; or
  7. If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided; and
  8. The beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC – i.e., a Heavy Duty PWC is covered for a beneficiary weighing 285 – 450 pounds; a Very Heavy Duty PWC is covered for a beneficiary weighing 428 – 600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 pounds or more.
  9. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.
  10. Use of a power wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver.
  11. The beneficiary has not expressed an unwillingness to use a power wheelchair in the home.

If a PWC will be used inside the home and if coverage criteria (a)-(e) are not met, it will be denied as not reasonable and necessary.

If any POV or PWC is only for use outside the home, it will be denied as noncovered.

NOTE: A power mobility device may not be ordered by a podiatrist. If it is, it will be denied as noncovered.

As a reminder, if you choose to view the entire policy written for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the durable medical equipment benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Seat Lift Mechanisms ("Seat lifts")

Basic Description: A device that effectively assists a beneficiary in standing up and sitting down without other assistance.

SUMMARY: Seat lift mechanisms are covered under the Durable Medical Equipment benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that seat lifts are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire Seat Lift Mechanisms policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

A seat lift mechanism is covered if all of the following criteria are met:

  1. The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
  2. 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 beneficiary's condition.
  3. The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a beneficiary 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 beneficiaries who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
  4. Once standing, the beneficiary must have the ability to ambulate.

Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the beneficiary, and effectively assist a beneficiary in standing up and sitting down without other assistance. Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-like motion and jolts the beneficiary from a seated to a standing position.

The physician ordering the seat lift mechanism must be the treating physician or a consulting physician for the disease or condition resulting in the need for a seat lift. The physician's record must document that all appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the beneficiary to transfer from a chair to a standing position.

A seat lift mechanism placed over or on top of a toilet, any type is non-covered.

As a reminder, if you choose to view the entire policy written for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the durable medical equipment benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Walkers  

Basic Description: An assistive device made of metal tubing, used to aid a patient in walking.

SUMMARY: Walkers are covered under the Durable Medical Equipment benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that walkers are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire Walkers policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

As you review this information, Note the use of the words "and" and "or". This is very important! If a policy states that you must have "this" AND "that" – then you must have both. If a policy states you need "this" OR "that" – you may only need one or the other to meet the requirements.
There are several different types of walkers for Medicare beneficiaries. The specific type of walker you received/or many have received is determined by your physician.

A standard walker and related accessories are covered if all of the following criteria (1-3) are met:

  1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.

    A mobility limitation is one that:
    1. Prevents the beneficiary from accomplishing the MRADL entirely, or
    2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform the MRADL, or
    3. Prevents the beneficiary from completing the MRADL within a reasonable time frame; and
  2. The beneficiary is able to safely use the walker; and
  3. The functional mobility deficit can be sufficiently resolved with use of a walker.

If all of the criteria are not met, the walker will be denied as not reasonable and necessary.

A heavy duty walker is covered for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. If a heavy duty walker is provided and the beneficiary weighs 300 pounds or less, it will be denied as not reasonable and necessary.

A heavy duty, multiple braking system, variable wheel resistance walker is covered for beneficiaries who meet coverage criteria for a standard walker and who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. Obesity, by itself, is not a sufficient reason for this walker. If this walker is provided and the additional coverage criteria are not met, it will be denied as not reasonable and necessary.

The medical necessity for a walker with an enclosed frame has not been established. Therefore, if an enclosed frame walker is provided, it will be denied as not reasonable and necessary.

A walker with trunk support is covered for beneficiaries who meet coverage criteria for a standard walker and who have documentation in the medical record justifying the medical necessity for the special features. If this walker is provided and the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary.

Leg extensions are covered only for beneficiaries 6 feet tall or more.

As a reminder, if you choose to view the entire policy written for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the durable medical equipment benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Manual Wheelchair Bases ("Wheelchair")

Basic Description: A mobile chair equipped with large wheels and brakes used to transport patients or to allow disabled persons to move themselves from one place to another.

SUMMARY: Wheelchair options and accessories are covered under the Durable Medical Equipment benefit defined by the Social Security Act. Use of the word "covered" does not imply payment. It simply means that wheelchairs are a benefit of the Medicare program and that payment will be considered if the Medicare beneficiary meets certain medical criteria and the certifying physician has conducted all necessary tests and documentation required for payment. If you would like to learn more about the Durable Medical Equipment benefit categories, please review our Beneficiary Guide to Understanding DMEPOSPDF.

If you choose to view the entire Manual Wheelchair Bases policyExternal Website which was written specifically for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

As you review this information, Note the use of the words "and" and "or". This is very important! If a policy states that you must have "this" AND "that" – then you must have both. If a policy states you need "this" OR "that" – you may only need one or the other to meet the requirements.

A manual wheelchair for use inside the home is covered if:

  1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
    1. Prevents the beneficiary from accomplishing an MRADL entirely, or
    2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
    3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.
  2. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
  3. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
  4. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.
  5. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
  6. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
  7. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

In addition to the general manual wheelchair criteria above, there are other wheelchair options and medical necessity requirements available.

In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable and necessary.

A transport chair is covered as an alternative to a standard manual wheelchair and if basic coverage criteria A-E and G above are met.

A standard hemi-wheelchair is covered when the beneficiary requires a lower seat height (17" to 18") because of short stature or to enable the beneficiary to place his/her feet on the ground for propulsion.

A lightweight wheelchair is covered when a beneficiary meets both criteria (1) and (2):

  1. Cannot self-propel in a standard wheelchair in the home; and
  2. The beneficiary can and does self-propel in a lightweight wheelchair.

A high strength lightweight wheelchair is covered when a beneficiary meets the criteria in (1) or (2):

  1. The beneficiary self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
  2. The beneficiary requires a seat width, depth, or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.

A high strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).

An ultra-lightweight manual wheelchair is covered for a beneficiary if criteria (1) or (2) is met and (3) and (4) are met:

  1. The beneficiary must be a full-time manual wheelchair user.
  2. The beneficiary must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a standard wheelchair, a standard hemi-wheelchair, lightweight wheelchair, or high strength lightweight manual wheelchair.
  3. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The LCMP may have no financial relationship with the supplier.
  4. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.

A heavy duty wheelchair is covered if the beneficiary weighs more than 250 pounds or the beneficiary has severe spasticity.

An extra heavy duty wheelchair is covered if the beneficiary weighs more than 300 pounds.

A manual wheelchair with tilt in space is covered if the beneficiary meets the general coverage criteria for a manual wheelchair above, and if criteria (1) and (2) are met:

  1. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The LCMP may have no financial relationship with the supplier.
  2. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.

A custom manual wheelchair base is covered if, in addition to the general coverage criteria above, the specific configuration required to address the beneficiary's physical and/or functional deficits cannot be met using one of the standard manual wheelchair bases plus an appropriate combination of wheelchair seating systems, cushions, options or accessories (prefabricated or custom fabricated), such that the individual construction of a unique individual manual wheelchair base is required.

A custom manual wheelchair is not reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).

If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not reasonable and necessary.

If the manual wheelchair is only for use outside the home, it will be denied as noncovered, no benefit, as the DME benefit requires use within the home for coverage eligibility.

As a reminder, if you choose to view the entire policy written for durable medical equipment suppliers, remember that the policy is very complex and may not be easy to read or understand. Any questions you may have regarding your equipment/service and payment for that equipment/service must be directed to 1.800.MEDICARE. CGS Jurisdiction C cannot answer beneficiary questions nor do we provide beneficiary services through our website. We are providing this coverage information as a courtesy to assist you in better understanding requirements for payment consideration.

Disclaimer All items billed to Medicare require a prescription. For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category – in this case, the durable medical equipment benefit, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

Medicare does not automatically assume payment for a durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item that was covered prior to a beneficiary becoming eligible for the Medicare Fee For Service (FFS) program. When a beneficiary receiving a DMEPOS item from another payer (including Medicare Advantage plans) becomes eligible for the Medicare FFS program, Medicare will pay for continued use of the DMEPOS item only if all Medicare coverage, coding and documentation requirements are met. Additional documentation to support that the item is reasonable and necessary, may be required upon request of the DME MAC.

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.

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Posted: 05.28.15

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