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Medicare / Insurance Guide
Coverage Criteria
(This is the coverage criteria for Medicare)
You can use this guide
to estimate the minimal expected coverage under a private insurance plan.
BUT - Private Insurance plans will differ. You
must review your individual policy to determine your exact coverage and coverage
criteria.
Wheelchairs
Walking
Aids
Home
Care Beds
Bathroom
Safety
Oxygen
and Respiratory
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Manual
Wheelchairs
Medicare Coverage
Criteria
A standard wheelchair
is covered if the patients condition is such that without the use of a
wheelchair, he/she would otherwise be bed or chair confined.
A standard
hemi-wheelchair is covered when the patient requires a lower seat height
(17" to 18") because of short stature or to enable the patient to
place his/her feet on the ground for propulsion.
A lightweight
wheelchair is covered when:
- the patient cannot
self propel in a standard wheelchair using arms and/or legs, and
- the patient can and
does self-propel in a lightweight wheelchair.
A high strength
lightweight wheelchair is covered when:
- the patient
self-propels the wheelchair while engaging in frequent activities that can
not be performed in a standard or lightweight wheelchair, and/or
- the patient
requires a seat width, depth or height that can not be accommodated in a
standard, lightweight or hemi-wheelchair, and spends at least two hours per
day in the wheelchair .
A heavy duty
wheelchair is covered if the patient weights more than 250 pounds or the patient
has severe spasticity.
An extra heavy duty
wheelchair is covered if the patient weights more than 300 pounds.
A custom wheelchair
base is covered only if the feature is not available as an option to an already
manufactured base.
Required
Documentation: CMN
A certificate of
medical necessity, which has been filled out, signed and dated by the physician,
must be kept on file by the supplier. The CMN for manual wheelchairs is HCFA
Form 844.
Motorized
/ Power Wheelchair Base
Medicare Coverage
Criteria
A power wheelchair is
covered when all of the following criteria are met:
- The patient's
condition is such that without the use of a wheelchair the patient would
otherwise be bed or chair confined;
- And, the patient's
condition is such that a wheelchair is medically necessary and the patient
is unable to operate a wheelchair manually;
- And, the patient is
capable of safely operating the controls for the power wheelchair.
A patient who requires
a power wheelchair is usually nonambulatory and has severe weakness of the upper
extremities due to a neurologic, muscular or cardiopulmonary disease or
condition.
Required
Documentation: CMN
The supplier must keep
a certificate of medical necessity, which has been filled out, signed and dated
by the physician, on file.
Wheelchair
Options and Accessories
Medicare Coverage
Criteria
Options and
accessories for wheelchairs are covered if the following criteria are met:
- The patient has a
wheelchair that meets Medicare coverage criteria, and
- The patient's
condition is such that without the use of a wheelchair, he/she would
otherwise be bed or chair confined (a patient may qualify for a wheelchair
and still be considered bed confined), and
- The options /
accessories are necessary for the patient to perform one or more of the
following activities:
- function in the home
- perform instrumental activities of daily living.
An option / accessory
that is beneficial primarily in allowing the patient to perform leisure or
recreational activities in not covered.
Adjustable arm height
option is covered if the patient requires an arm height that is different than
that available using non-adjustable arms and the patient spends at least
2 hours per day in the wheelchair.
Hook-on headrest
extension is covered if the patient:
- has weak neck
muscles and needs a headrest for support, or
- meets the criteria
for and has a reclining back on the wheelchair.
A fully reclining back
option is covered if the patient spends at least 2 hours per day in the
wheelchair and has one or more of the following conditions / needs:
- Quadriplegia;
- Fixed hip angle;
- Trunk or lower
extremity casts / braces that require the reclining back feature for
positioning;
- Excess extensor
tone of the trunk muscles; and/or
- The need to rest in
a recumbent position two or more times during the day and transfer between
wheelchair and bed is difficult.
A solid seat insert is
covered when the patient spends at least 2 hours per day in the wheelchair.
A safety belt / pelvic
strap is covered if the patient has weak upper body muscles, upper body
instability or muscle spasticity that requires use of this item for proper
positioning.
Elevating legrests are
covered if:
- the patient has a
musculoskeletal condition or the presence of a cast or brace which prevents
90 degree flexion at the knee; or
- the patient has
significant edema of the lower extremities that requires having an elevating
legrest; or
- the patient meets
the criteria for and has a reclining back on the wheelchair.
A non-standard seat
width, depth or height is covered only if:
- the ordered item is
at least 2 inches greater than or less than a standard option, and
- the patient's
dimensions justify the need.
A crutch and cane
holder is not medically necessary.
An arm trough is
covered if the patient has quadriplegia, hemiplegia or uncontrolled arm
movements.
Required
Documentation: CMN
Wheelchair options /
accessories that require a CMN are detachable, adjustable height armrests;
fixed, adjustable height armrests; reclining back feature; and elevating
legrests. For these items, a CMN that has been filled out, signed and dated by
the ordering physician must be kept on file by the supplier. For items not
requiring a CMN, an order for the item, which has been signed and dated by the
ordering physician, must be kept on file with the supplier.
Power
Operated Vehicles (POVs)
Medicare Coverage
Criteria
A power Operated
Vehicles is covered when all of the following criteria are met:
- The patient's
condition is such that a wheelchair is required for the patient to get
around in the home,
- the patient is
unable to operate a manual wheelchair,
- the patient is
capable of safely operating the controls for the POV, and
- the patient can
transfer safely in and out of the POV and has adequate trunk stability to be
able to safely ride in the POV.
Most POVs are ordered
for patients who are capable of ambulation within the home but require a power
vehicle for movement outside the home, but POVs will be denied as not medically
necessary in these circumstances.
A POV that is
beneficial primarily in allowing the patient to perform leisure or recreational
activities will be denied as not medically necessary.
If a POV is covered, a
wheelchair provided at the same time or subsequently will usually be denied as
not medically necessary.
A POV is usually
covered only if it is ordered by a physician who is one of the following
specialties: Physical Medicine, Orthopedic Surgery, Neurology or Rheumatology.
Required
Documentation: Prior Authorization, CMN, Order Prior to Delivery
This item may receive
prior authorization. A CMN must be filled out, signed and dated by the ordering
physician and kept on file by the physician and / or the supplier.
Canes and
Crutches
Medicare Coverage Criteria
Canes and crutches
are covered when prescribed by a physician for a patient with a condition
causing impaired ambulation and when there is a potential for ambulation.
Required
Documentation: Order
An order for canes
and crutches which is reviewed, signed and dated by the ordering physician
must be kept on file by the supplier. The medical records must contain
information which supports the medical necessity of the item ordered.
Walkers
Medicare Coverage Criteria
A walker is covered if
both of the following criteria are met:
- When prescribed by
a physician for a patient with a medical condition impairing ambulation and
there is a potential for ambulation; and
- When there is a
need for greater stability and security than provided by a cane or crutches.
Required
Documentation: Order
An order for the
walker which is signed and dated by the treating physician must be kept on file
by the supplier. The medical records must contain information which supports the
medical necessity of the item ordered.
Patient
Lifts
Medicare Coverage
Criteria
A hydraulic patient
lift with sling or seat is covered if transfer between bed and a chair,
wheelchair or commode requires the assistance of more than one person, and
without the use of a lift, the patient would be bed confined.
Tub lifts and electric
patient lifts are considered convenience items and are not
covered.
Required
Documentation: Order
An order for the
patient lift, which is signed and dated by the ordering physician, must be kept
on file by the supplier. The medical records must contain information which
supports the medical necessity of the item ordered.
Hospital
Beds - Fixed Height
Medicare Coverage
Criteria
A fixed height bed is
covered if one or more of the following indications are met:
- A patient who
requires positioning of the body in ways not feasible with an ordinary bed
in order to alleviate pain.
- A patient who
requires the head of the bed to be elevated more than 30 degrees most of the
time due to congestive heart failure, chronic pulmonary disease or problems
with aspiration. Pillows or wedges must have been tried and failed to
achieve the desired clinical outcome.
- A patient who
requires traction equipment which can only be attached to a hospital bed.
Required
Documentation: CMN
A CMN for the item
which has been completed, signed and dated by the ordering physician must be
kept on file by the supplier.
Hospital
Beds - Variable Height
Medicare Coverage
Criteria
A variable height bed
is covered if the patient qualifies for a fixed height hospital bed, and
the patient requires a
bed height different than a fixed height hospital bed to permit transfers to
chair, wheelchair or standing position.
Required
Documentation: CMN
A CMN for the item
which has been completed, signed and dated by the ordering physician must be
kept on file by the supplier.
Hospital
Beds - Semi-Electric
Medicare Coverage
Criteria
A variable height bed
is covered if the patient qualifies for a fixed height hospital bed, and
the patient requires
frequent changes in body position and / or has an immediate need for a
change in body position.
Required
Documentation: CMN
A CMN for the item
which has been completed, signed and dated by the ordering physician must be
kept on file by the supplier.
Hospital
Beds - Total-Electric
Medicare Coverage
Criteria
An electric bed height
adjustment feature is not covered; it is a convenience feature.
If the documentation
supports a lower level bed, payment is based on the allowance for the least
costly alternative.
Trapeze
Bars
Medicare Coverage
Criteria
A trapeze bar is
covered when a patient needs this device to sit up because of a respiratory
condition, to change body position for other medical reasons or to get in and
out of bed.
A trapeze bar is
covered when it is either an integral part of or used on a hospital bed, and it
has been determined that both the hospital bed and the trapeze bar are medically
necessary.
When "free
standing" trapeze equipment is prescribed, it must meet the same criteria
as the attached equipment and the patient must not rent
or own a hospital bed.
Required
Documentation: Order
An order for trapeze
bars which is signed and dated by the ordering physician must be kept on file by
the supplier. The medical records must contain information which supports the
medical necessity of the item ordered.
Pressure
Reducing Support Surfaces
Medicare Coverage
Criteria
Support Surfaces
products are separated into 2 groups.
Group 1:
- Alternating
pressure pad with pump.
- Dry pressure
mattress.
- Gel pressure
overlay for mattress.
- Air pressure
mattress.
- Water pressure
mattress.
- Gel pressure
mattress.
- Air pressure
overlay for mattress.
- Water pressure
overlay for mattress.
- Dry pressure
overlay for mattress.
Group 2:
- Low Air Loss
Therapy Bed - powered.
- Alternating
pressure reducing mattress - powered.
- Advanced pressure
reducing overly - non-powered.
- Air overlay for
mattress - powered.
- Advanced pressure
reducing mattress - non-powered.
The staging of
pressure ulcers used in the Medicare Coverage criteria is as follows:
| Stage
I |
Nonblanchable
erythema of intact skin. |
| Stage
II |
Partial
thickness skin loss involving epidermis and / or dermis. |
| Stage
III |
Full
thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down to, but not through, underlying fascia. |
| Stage
IV |
Full
thickness skin loss with extensive destruction, tissue necrosis or
damage to muscle, bone or supporting structures |
Patients needing
pressure reducing support surfaces should have a care plan which has been
established by the patient's physician or home care nurse, and is documented in
the patient's medical records, and generally should include the following:
- Education of
patient and caregiver on the prevention and / or management of pressure
ulcers.
- Regular assessment
by a nurse, physician or other licensed healthcare practitioner.
- Appropriate turning
and positioning.
- Appropriate
wound care (for stage II,
III
and IV
ulcer).
- Appropriate
management of moisture and incontinence.
- Nutritional
assessment and intervention consistent with the overall plan of care.
Commodes
Medicare Coverage Criteria
A commode is covered
when the patient is incapable of utilizing regular toilet facilities.
Detachable arms are
covered when used to facilitate transferring the patient or if the patient has a
body configuration that requires extra width. Extra wide commodes are covered if
the patient is obese. Mobile commode chairs are not covered.
Required
Documentation: Order
An order for the
commode which is signed and dated by the treating physician must be kept on file
by the supplier. The medical records must contain information which supports the
medical necessity of the item ordered.
Oxygen
Medicare Coverage Criteria
Medicare coverage of
home oxygen therapy is available only for patients with significant hypoxemia in
the chronic stable state provided the following conditions are met:
- The attending or
consulting physician has determined that the patient suffers a severe lung
disease or hypoxia-related symptoms that might be expected to improve with
oxygen therapy;
- The patient's blood
gas levels indicate the need for oxygen therapy; and
- Alternative
treatment measures have been tried or considered and have been deemed
clinically ineffective.
Covered Blood Gas
Values
Group 1
- Goverage is provided for patients with significant hypoxemia evidenced by any
of the following:
- An arterial PO2 at
or below 55mm. Hg, or an arterial oxygen saturation at or below 88 percent,
taken at rest. When a PO2 of greater than 55mm. Hg. is submitted, the
service will be denied as not medically necessary unless "Group 2"
criteria are met.
- An arterial PO2 at
or below 55mm Hg., or an arterial saturation at or below 88 percent taken
during sleep for a patient who demonstrates an arterial PO2 at or above 56
mm. Hg., or an arterial oxygen saturation at or above 89 percent while
awake, of a greater than normal fall in oxygen level during sleep (a
decrease in arterial PO2 more than 10 mm. Hg., or a decrease in arterial
oxygen saturation more than 5 percent) associated with "P"
pulmonale n EKG, documented pulmonary hypetension and erythrocytosis. In
either of these cases, coberage is provided only for nocturnal use of
oxygen.
- An arterial PO2 at
or below 55 mm. Hg. or an arterial oxygen saturation at or below 88 percent
taken during activity for a patient 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, supplemental oxygen is provided
for use during exercise if it is documented that the use of oxygen improves
the hypoxemia that was demonstrated during exercise when the patient was
breathing room air.
Group 2
- Coverage is available for patients whose arterial PO2 is 56 to 59 mm. Hg. or
whose arterial blood oxygen saturation is 89 percent if any of the following are
documented:
- Dependent edema
suggesting congestive heart failure;
- pulmonary
hypertension or cor pulmonale, determined by measurment of pulmonary artery
pressure, gated blood pool scanechocardiogram, or "P" pulmonale of
EKG (P wave greater than 3 mm in standard leads II, II or AVF); or
- Erythrocythemia
with a hematocrit greater than 56 percent.
Non-Covered Conditions
Conditions for which
Oxygen therapy is not considered Medically Necessary by Medicare:
- Angina pectoris in
the absence of hypoxemia.
- Dyspnea without cor
pulmonale or evidence of hypoxemia.
- Severe peripheral
vascular disease resulting in clinically evident desaturation in one or more
extremities. There is no evidence that increased PO2 will improve the
oxygenation of tissues with impaired circulation.
- Terminal illnesses
that do not affect the respiratory system.
- Medicare will
presume that home use of oxygen is not medically necessary for patients with
arterial PO2 levels at or above 60 mm. Hg., or arterial blood oxygen
saturation at or above 90 percent.
Required
Documentation: CMN, HCFA Form 484.2
The Certificate of
Medical Necessity (CMN) for home oxygen use is HCFA Form 484.2. Federal Law
(OBRA 1990) mandates specific sections of this form must be completed by the
physician or their staff.
Section A - Contains
identifying information, such as patient's name, address, Medicare number and
physician or supplier information. This section is usually completed by the
supplier.
Section B - This
section must be completed by the physician, the physician's employee or another
clinician involved in the care of the patient. If someone other than the
physician completes Section B, the physician must review the answers to assure
their correctness.
Section C - This
section must be completed by the supplier prior to sending the CMN to the
physician. The supplier's charges and Medicare fee schedule allowance are
provided for the physician's information.
Section D - If the
information in Section B and the order information in Section C is correct, then
the physician signs and dates the CMN and mails it to the supplier. The
physician is encouraged to keep a copy of the CMN in the patient's medical
record.
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