Berkshire Senior Online

By Margie Ware, Regional SHINE Director

Although the vast majority of the questions we receive at the SHINE program are about prescription medications and supplemental Medicare insurance, probably our most vexing questions come in the area of durable medical equipment, often referred to as DME.

There are literally inch thick books written about what equipment is and is not covered by Medicare, and what the criteria are for receiving coverage. Recently I learned that Medicare would pay for a client’s oxygen tank, but ONLY if the individual’s lung capacity was below 90%. So someone with emphysema and 91% capacity is faced with an expensive choice. And since supplemental insurance picks up the balance of what Medicare does not pay, a denial by Medicare for a service means that the supplemental insurance automatically denies coverage also.

From a public policy perspective one can understand why there are restraints and constrictions. We listen to TV magazine shows all the time that show unscrupulous vendors preying on the Medicare system and issuing everyone in town a cane, a walker or a wheelchair. The regulations are there for a reason. But, by the same token, it is often difficult to navigate the system and make sure that a patient is receiving coverage for equipment when necessary. As always, when Medicare denies coverage for a service, individuals should always feel free to call their local Councils on Aging, or the Elder Services office (413 499-0524/800 957-3557) and ask for a SHINE volunteer to answer any question.

Here are some commonly asked questions about DME which may give you some basic information on the kinds of things that Medicare covers in terms of equipment and supplies:

Q. Is Medicare now covering supplies for non-insulin dependent diabetics?

A. Effective July 1, 1998, Medicare covers diabetic supplies for insulin and non-insulin dependent diabetics.

Q. Does Medicare cover insulin and syringes?

A. Medicare does not cover syringes nor insulin used with syringes. Medicare only provides reimbursement for insulin for certain Type I diabetics when it is used as a supply that is administered subcutaneously through an insulin infusion pump.

Q. Why is my claim for test strips denied as "too many services billed?"

A. The correct number of units that should be billed is one unit if you received 50 test strips or two units if you received 100 strips. Medicare will allow 100 test strips per month if the beneficiary meets the coverage criteria.

Q. Does Medicare reimburse for wheelchairs?

A. Medicare reimburses for wheelchairs used in the home if it is determined to be "medically necessary." Medicare requires certain types of wheelchairs to be rented first before the option to purchase is available. This helps to insure that it is the correct chair for the beneficiary, and allows time to make sure that the chair is working correctly while the supplier is still responsible for maintenance.

Q. Why isn’t the rental of a wheelchair or oxygen covered in a skilled nursing facility (SNF)?

A. Durable Medical Equipment is only covered if it is prescribed for home use. A SNF doesn’t meet the definition of a beneficiary’s home.

Q. What are commonly used items that Medicare does NOT reimburse for?

A. Medicare does not reimburse for:

– Wheelchair ramps

– Hearing aids

– Wigs

– Surgical Stockings

– Bathroom Supplies (tub rails, etc.)

– Adult diapers

– Oxygen while traveling on an airplane

– Stair glides

Q. Does Medicare cover eyeglasses?

A. If you had a cataract removed, Medicare will provide reimbursement for the first pair of glasses you receive after the surgery.

Q. Does Medicare cover a blood pressure monitor?

A. Medicare only reimburses for a blood pressure monitor if the beneficiary is receiving home dialysis.

Q. Does Medicare reimburse for Ensure?

A. Medicare does not reimburse for Ensure if it is taken orally. Parenteral and Enternal Nurtrition criteria must be met for coverage.

Q. Does Medicare cover a seat lift if a wheelchair has already been covered?

A. Medicare will deny a seat lift mechanism if the beneficiary has had a covered wheelchair because the two items are counter-indicated.

Q. Does Medicare cover a Power Operated Vehicle (scooter)?

A. Medicare will provide reimbursement for a POV if the beneficiary meets the coverage criteria. Prior authorization of medical necessity may be obtained from the vendor that regulates Durable Medical Equipment. If a scooter is reimbursed, a wheelchair cannot be reimbursed simultaneously.

As in any complex situation, the best rule of thumb is to ask your physician BEFORE you rent or purchase equipment whether this will be covered by Medicare. DME suppliers are also knowledgeable about reimbursement policies. Also remember that if you need DME, then you need it! If Medicare doesn’t reimburse for it, don’t ignore your need. If financial hardship is an issue, there are a variety of organizations that may be able to assist you and your family in obtaining the equipment you need.