Coverage Criteria

Weakened muscles and poor balance combined with water and moisture in the air can make bathroom surfaces slippery. This type of environment affects the beneficiary’s ability to travel to and from the toilet without falling. The potential of falling is reduced greatly with the use of a commode by making is easier for the individual to get on and off the toilet. Some commodes can function as a portable toilet, reducing the number of trips one has to take to the bathroom. Beneficiaries may use Medicare to cover the cost of commodes if one or more of the following reasons are met:

  • Illness has left the body weak and unbalanced, making trips to and from the bathroom difficult and dangerous.
  • Walking the distance to the bathroom has become dangerous temporarily as a result from surgery.
  • Getting on and off the toilet has become difficult from joint problems and aging has left the legs weak.
  • Travelling to and from the toilet and on/off the toilet has become difficult due to poor balance.

Commodes come in many styles and sizes. They include:

  • Stand-alone toilets for use at the bedside or in the bathroom. These come in three basic styles:
    • Standard commode chairs (basic unit)
    • Extra-wide commode chairs (for people over 250 pounds)
    • Drop-arm commode chairs (arms fold down)
  • Commodes with wheels
  • Tall, toilet-covering commodes
  • Multi-function commodes (toilet, shower chair, bedside chair or wheelchair)
  • Commodes that attach to the toilet seat, making the toilet taller and easier to use

Red Rock Medical Supply wants to make sure you are equipped with the right seat for your needs. We will work with you to ensure your commode meets your needs, is safe and easy to use, and is comfortable to sit on.

 

HOSPITAL BEDS

Medicare will cover hospital beds if you can show a medical necessity for the bed. You must also, be covered under Medicare Part B and have an assessment done by your doctor. Documentation must be put in your medical records an order (prescription) must be written for the equipment by your doctor.

Your medical assessment must include on or more of the following to qualify:

  • Changing positions is not possible on a normal bed due to an existing medical condition.
  • Require positioning to relieve pain, but not possible in a normal bed.
  • Conditions such as congestive heart failure, breathing complications, or other types of problems require sleep with the head of the bed higher than 30 degrees and pillows or wedges have been considered and ruled out.
  • Require traction equipment that must be attached to a hospital bed.
  • A variable height bed is covered if it is necessary to permit transfers to a chair, wheelchair, or standing position.
  • A semi-electric bed is covered if you require frequent changes in body position and/or have an immediate need for a change in body position.
  • If you weigh over 30 pounds a heavy-duty/extra-wide bed can be covered under Medicare.
  • If you have a respiratory condition requiring you to sit up, change body positions due to other medical reasons, or to get in and out of bed trapeze equipment is covered.
  • Have a Certificate of Medical Necessity that is completed, signed and dated by the treating doctor.

 

MOBILITY ASSISTIVE EQUIPMENT; CANES, WALKERS, SCOOTERS, AND WHEELCHAIRS

 The ability to get around easily decreases with age. Movements like reaching, bending, going up and down stairs, and getting in and out of cars and bathtubs becomes increasingly more difficult. Even walking becomes harder as some older people lose their ability to balance and muscles become weakened. Physical changes that occur with aging are normal, but affect mobility. Some of these changes include arthritis in the joints, slower reflexes, loss of bone tissue (osteoporosis, especially in women), and less energy.

Mobility aids like canes, walkers, electric wheelchairs, and electric scooters can help those with decreased mobility safely travel within their homes, to and from the grocery store, and other various activities and maintain their independence. The best mobility aid for you is determined by overall strength and balance. If you have good body strength and balance, the right mobility aid for you is probably a cane. If you aren’t as steady on your feet, you may need the extra support of a walker or wheeled walker.  Your doctor may recommend a power wheelchair or power scooter if a walker or wheeled walker is not suitable to your needs.

In order to get a mobility aid, you’ll need to be evaluated by your doctor first. Here are some of the specific things they will measure:

  • Your upper-body strength: Upper-body strength is needed to balance on a scooter, which is less supportive than a power wheelchair.
  • Posture: You must also demonstrate an ability to maintain an upright posture to stay on a scooter. An electric wheelchair offers much more support and reinforcement for a weak upper body and posture.
  • Arm, hand and leg strength: Scooters operate by means of hand controls and brakes. If you do not have the arm, hand, and leg strength required to operate a scooter. A power chair with joystick controls may be more suitable.

After a doctor evaluation, you will know which mobility aid is best for you and you can begin looking into different power chair and scooter models and accessories.

Electric Scooters

All models of scooters come with the same basic components and features. They have a seat on top of a wheeled platform and a column (tiller) at the front with controls or hand-rests. The base unit contains the drive system and battery and offers support for your feet.

Your doctor or therapist will help determine your choice based on specific results of your physical capabilities. If you have less hand strength operating hand controls will be difficult and other types of controls are available. The following are other factors to consider:

 

  • Will you primarily use your scooter inside or outside? Electric scooters are available in three- or four-wheeled models. The three-wheeled model is easier to maneuver and operate indoors, while the four-wheeled model offers more stability and runs smoother on rough or unstable terrain.
  • Will you be transporting your scooter in a vehicle? Full-size scooters are more difficult to transport and require an additional scooter lift to be placed on your vehicle. Portable scooters have the option of being folded and placed in a vehicle for easy transport.

Medicare coverage for electric mobility scooters

If your doctor deems it medically necessary for you to have an electric mobility scooter Medicare Part B will cover most of the cost. The scooter cannot be used as a “recreational vehicle” and must be used primarily moving about your home. After meeting your Part B deductible you may be required to pay up to 20 percent.

Other requirements for Medicare coverage include:

  • A doctor or other qualified health provider must provide an evaluation.
  • A “Certificate of Medical Necessity” must be issued, and the evaluation must be documented stating the need of a mobility device for a medical condition.
  • Prior to Medicare being billed you must present a prescription or order to a Medicare-approved scooter-supplier.
  • You must be able to get on and off the scooter and safely operate it.
  • You must have good vision
  • You must have a health condition that causes difficulty for you to move around in your home

 

NEBULIZERS

Medicare will cover the cost of nebulizers, medication, and supplies for patients if a doctor declares it a medical necessity. Medicare will also cover treatment for respiratory problems and certain other diseases. To ensure that Medicare pays for your nebulizer follow the steps below:

  • Only your doctor can prescribe a nebulizer for you, so do not order anything until you have visited your doctor.
  • The doctor must give you a signed and dated prescription, as well as documenting the need in your medical records to support the medical necessity for a nebulizer.
  • Before Medicare is billed the order must be received by the supplier and kept on file by the supplier.

It is likely you will have to follow your plan’s steps for approval if you have a Medicare Advantage Plan such as an HMO or PPO. If you have questions regarding the steps to take call you plan’s customer service number and ask about their steps for coverage of a nebulizer

Certain respiratory problems and other illness that cause breathing problems or require the equipment for a nebulizer will be covered by Medicare, and can include any of the following conditions:

  • Asthma
  • Brochiectasis
  • Chronic Bronchitis
  • Complications of organ transplants
  • Cystic Fibrosis
  • Emphysema
  • Human immunodeficiency virus (HIV)
  • Persistent thick or tenacious pulmonary secretions
  • Pneumocytosis
  • Tracheostomy

NON-COVERED ITEMS (PARTIAL LIST)

  • Adult diapers
  • Bathroom safety equipment
  • Elastic garments
  • Emergency communicators
  • Exercise equipment
  • Grab bars
  • Hearing aides
  • Humidifiers/air purifiers
  • Low vision aides
  • Massage devices
  • Raised toilet seats
  • Stair lifts
  • Syringes/Needles
  • Van Lifts or Ramps

 

OXYGEN

If you have a breathing condition that will improve with the help of oxygen, Medicare will help cover most of the cost of home oxygen equipment and supplies. It is necessary that you provide documentation stating home oxygen will improve function, and treatment is reasonable for an illness or injury before Medicare will submit payment for oxygen equipment and supplies. To ensure that Medicare will cover your home oxygen equipment and supplies follow these steps below:

  • You must have a written prescription by your doctor or other health care provider subscribing you oxygen equipment and supplies.
  • In addition to a written prescription, the doctor must document your need for oxygen in your medical records.
  • The supplier must receive the order before Medicare is billed and the supplier must keep it on file.

Medicare will pay for the oxygen equipment and supplies when:

  • It will be used repeatedly
  • It is needed for a medical purpose
  • It is needed for an illness or injury
  • It is for use in the home

To qualify for oxygen equipment and supplies:

  • Your doctor must document a condition that interferes with your ability to breathe or a severe lung disease.
  • Your gas level falls within a specific range
  • Other alternative measures were tested and found unhelpful
  • Your condition might improve with the use of oxygen

Under the above conditions, Medicare helps pay for:

  • Systems for furnishing oxygen
  • Containers that store oxygen
  • Tubing and related supplies for the delivery of oxygen
  • Oxygen contents
  • Portable oxygen units when used to move around the home

Medicare will not pay for:

  • Portable oxygen for use during sleep only
  • Portable oxygen when provided only as a backup to a stationary oxygen system

Oxygen will be paid as a rental for the first 36 months. If you still need the equipment Medicare will no longer make payments on the rental; however, if you still need the equipment your provider will continue to provide the equipment for you for an additional 24 months. During this two-year period, Medicare will pay your provider for refilling oxygen cylinders, for maintenance, and servicing. After 60 months of service through Medicare you have the option of receiving new equipment.

 

PATIENT LIFTS

There are several types of lifts and each will have different criteria for coverage qualification. Once your doctor has deemed a patient lift medically necessary, Medicare will help cover the costs. Take the following steps in order to get covered by Medicare

  • Only your doctor can write a prescription for the equipment for you, so do not order anything until you have visited your doctor.
  • The doctor must document the need in your medical records and give you a signed and dated order (prescription) for the equipment.
  • The supplier must receive the order before Medicare is billed and the supplier must keep it on file.
  • If you receive your Medicare through a Medicare Advantage Plan (like a HMO or PPO) it is likely you will have to follow the plan’s steps for approval and purchase. Make a point of calling your plan’s customer service number and ask about their steps for coverage of a patient lift.

Each type of lift will have its own set of criteria for you to qualify. For example:

In order for Medicare to help pay for a bed lift:

  • You must need the assistance of at least two people to be transferred from the bed to a wheelchair, chair, or commode.
  • Without the use of a lift you would be confined to the bed.

In order for Medicare to pay for a seat lift mechanism, you must have one or more of the following:

  • Your doctor must believe the lift will help stop the deterioration of your condition or help improve it.
  • You must be unable to stand completely from any chair, but able to walk independently or with a walker or cane once up.
  • You must be suffering from sever arthritis of the knee or hip.
  • You must be suffering from a severe neuromuscular disease.

A Certificate of Medical Necessity is required for a lift. Your Medicare supplier and doctor will know when that documentation is required

Patient lifts are capped rental items, meaning they cannot be purchased outright. Medicare must make 13 payments toward the purchase of the equipment, then you will own it.

Medicare will terminate payment for any mobility aids you use, such as a cane, crutches, walkers, scooters, and wheelchairs if an electric lift or multi-positional support lift is provided.

 

RESPIRATORY ASSIST DEVICES

If you have a clinical disorder a respiratory assist device (RAD) is covered. A clinical disorder is categorized as:

  • Central sleep apnea (CSA) or complex sleep apnea (CompSA)
  • Hypoventilation syndrome
  • Restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities)
  • Severe chronic obstructive pulmonary disease (COPD)

Diverse tests may need to be performed to establish diagnosis criteria based on sleep-associated hypoventilation. Symptoms may include daytime tiredness, excessive fatigue, morning headaches, and shortness of breath. Your doctor must document in your medical records one or more of the above diagnosis groups’ criteria before Medicare will help with cost.

If you are accommodating with treatment, have exhausted your existing supply and you have specifically requested such supplies, Medicare will pay for replacement masks, tubing, and other necessary supplies.

 

SEAT LIFT MECHANISMS

In order for Medicare to pay for a seat lift mechanism, you must meet one or more of the following guidelines:

  • You must have severe neuromuscular disease
  • You must have arthritis of the hip or knee
  • Your doctor must prescribe the lift mechanism as part of the treatment plan, with the belief it will improve the condition or impede deterioration in your condition.
  • You must be completely incapable of standing up from a regular armchair or any chair in your home.
  • Once standing, you must have the ability to ambulate.

The doctor who is treating you for the disease or condition resulting in the need for a seat lift must be the doctor prescribing the seat lift. Your physician recognizing that all other options such as, medication and physical therapy, have been exasperated and failed to allow you to transfer from a chair to a standing position must document such in your medical records.

If you use a wheelchair or scooter, this will prevent coverage for the seat lift, because, as above, you must be able to ambulate once you are standing.

Medicare does not cover the chair portion and you will be responsible for paying the full amount for the furniture component of the chair. Medicare will only pay for the lift mechanism portion.

Your equipment supplier must have a written order or certificate of medical necessity before this equipment can be delivered to you. Your supplier cannot receive proper documentation at a later date because if they do, Medicare cannot make payment for the equipment to you or the supplier. Please remain patient with your supplier while they continue to gather required documentation from your physician.

 

SUPPORT SURFACES

Group 1 products are intended to be positioned on top of a standard hospital bed or home mattresses. They can utilize gel, foam, water or air, and are covered if you are:

  • Completely immobile; OR
  • Have an ulcer on the trunk or pelvis or limited mobility and one or more of the following:
    • Altered sensory perception
    • Compromised circulatory status
    • Fecal or urinary incontinent
    • Impaired nutritional status

Group 2 products are typically powered pressures reducing mattresses and overlays. These products are covered if you have on or more of the three conditions:

  • A recent myocutaneous flap or skin graft for an ulcer on the trunk or pelvis within the last 60 days where you were placed on Group 2 or Group 3 support surface prior to discharge fromt eh hospital or aftercare facility.
  • Multiple Stage III or IV ulcers on the trunk or pelvis.
  • Multiple stage II ulcers on the pelvis or trunk while on a comprehensive treatment program for at least a month using a Group 1 product. The ulcers worsened or remained the same while using a Group 1 product.

A Group 2 support surface is typically covered until the ulcer is healed, or your doctor notes that it is not healing with care being modified to promote healing.

To determine whether the use of equipment is required a physician or healthcare professional must make monthly assessments. A home healthcare nurse may come to your home at your physician or healthcare professional’s request to make the assessments, or that you visit a wound care specialist.

Group 3 products are air-fluidized beds and are only covered if you meet ALL of the following conditions:

  • A stage III or stage IV pressure ulcer, and
  • Are bedridden or chair bound as the result of limited mobility, and
  • In the absence of an air-fluidized bed would require institutionalization, and
  • An alternate course of conservative treatment has been tried for at least one month without improvement of the wound, and
  • A trained caregiver is available to help with activities of daily living and other needs, and
  • All other alternative equipment has been considered and ruled out.

Your physician or healthcare professional must complete an assessment and evaluation after you complete a course of conservative therapy within one month prior to ordering the Group 3 support surface. In order to maintain coverage your physician or healthcare professional must re-evaluate you on a monthly basis and fill out a form to certify medical necessity.

Your medical equipment cannot be delivered to you without a written order from your physician, nor can they receive proper documentation at a later date because Medicare can never make payment for those products to you or your medical supplier. Please remain patient while your medical supplier collects all the necessary documentation from your physician.

If you have any other concerns or questions regarding Medicare coverage please visit the Medicare website at Medicare.com