Web Posted on: December 3, 1998

ACCESS TO MEDICAL EQUIPMENT THROUGH MEDICARE

Medicare is a federal health insurance program for aged and disabled persons. Unlike Medi-Cal, entitlement to Medicare services is not based on an individual's financial status. Rather, it is a health insurance program funded through employer and employee payroll taxes.

To qualify for Medicare, an individual must be eligible for:

• Security Benefits under Title II of the Social Security Act;
• federal retirement for those employees who retired on or after 1983; or
• Railroad Retirement benefits.

If not disabled, eligibility begins at age 65, even if the person elected to begin receiving retirement benefits at age 62. Persons with disabilities under the age of 65 may be eligible for Medicare if they have received Social Security or Railroad Retirement disability benefits for at least 24 months. Medicare benefits can continue for up to two years after a person with a disability has ceased receiving disability benefits because of successfully completing a trial work period. If a person who has completed a trial work period becomes disabled again within five years, Medicare begins immediately without going through a second two year waiting period. The disabled adult child of a Medicare recipient, or deceased Medicare recipient, is also eligible to receive Medicare benefits.

Medicare benefits are divided into Parts A and B. Part A covers hospital care, nursing home and home health care services. Part B covers outpatient hospital care, physician services, physical therapy, medical transportation, durable medical equipment and prostheses. Since the majority of assistive technology devices and services fall under Part B, this chapter will concentrate on that side of the program. Administration, service scope, authorization and appeals vary between the two parts.

The Medicare program is administered locally by private insurance companies called carriers. The Health Care Financing Administration (HCFA), a federal agency within the Health and Human Services Agency, contracts with private insurance companies in each area of the country to process claims for benefits from Medicare beneficiaries. However, application for Medicare benefits is made at local Social Security offices and questions concerning benefits should be directed there as well.

With respect to durable medical equipment provided under Part B, there are only four regional carriers that cover the entire nation. California is in Region D, which is administered by CIGNA from Nashville, Tennessee. Questions regarding coverage should be initially directed to local Social Security offices but if the answer there is unsatisfactory, it is possible to contact CIGNA at P.O. Box 690, Nashville, TN 37202, phone (615) 251-8182 or (800) 899-7095.

1. What assistive devices and services are available through Medicare Part B?

When Medicare covers assistive technology devices and services, it will generally be under Part B. Part B services include:

• physicians' services
• outpatient hospital services
• rural health clinic services
• comprehensive outpatient rehabilitation facility services
• physical and occupational therapy
• speech pathology services
• prosthetic devices
• durable medical equipment and
• diagnostic tests.

42 U.S.C. §§ 1395k & 1395x.

Technology that is necessary while institutionalized may be covered under Part A as part of the Medicare payment for institutional care. This may include prosthetics, orthotics, durable medical equipment and other devices also covered under Part B. The criteria for purchase is generally the same.

Medicare does not cover services that are considered routine or preventative. This includes routine physical examinations, dental care (except for emergency restorative services or where the jaw or bone supporting the teeth is involved), eye sight examinations, eyeglasses or contact lenses (except when associated with cataract surgery), hearing examinations, hearing aids and orthopedic shoes (except when required because of the symptoms of diabetes.) 42 U.S.C. § 1395y(a).

2. Which services and equipment will Medicare pay for?

Medicare will only pay for services and equipment that it determines to be reasonable and necessary. 42 U.S.C. § 1395y(a)(1)(A). Reasonable means that it is the lowest priced item that will meet the medical need of the beneficiary and that the amount paid is consistent with the amount Medicare has set as the allowed amount for this item. Necessity is established initially by the recipient's physician. The physician's report must justify the need for the item by describing the beneficiary's condition and how the recommended item will assist him/her.

HCFA expects carriers to refer to lists of approved and disapproved devices in determining necessity. If an item is on the approved list, it can be purchased if the individual can establish a need for it. If an item is on the disapproved list, carriers will not approve its purchase and the only recourse will be an appeal. See Question 14. If the requested item does not appear on either an approved or disapproved list, a case for its medical necessity should be made. The carrier may approve. If not, an appeal can be taken. Suppliers of durable medical equipment know whether a particular item is on an approved or disapproved list and should be consulted.

3. What durable medical equipment will Medicare provide and what are the limitations?

Medicare defines durable medical equipment as equipment that:

• can withstand use;
• is primarily and customarily used to serve a medical purpose;
• generally is not useful to a person in the absence of an illness or injury;
• is appropriate for use in the home (42 C.F.R. § 405.514(a));
• is necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a malformed body member (42 U.S.C. § 1395y(a)).

All of these elements must be satisfied before Medicare will purchase an item as durable medical equipment.

Medicare will pay for durable medical equipment under Part B on the basis of a lease-purchase, lump sum payment or rental. Medicare rules establish which payment option is used. In some circumstances, the Medicare carrier determines whether rental as opposed to lease-purchase or lump sum purchase is more cost effective. In some, the beneficiary is allowed to choose between rental and purchase. 42 C.F.R. § 405.514(c).

Assistive technology provided as durable medical equipment includes but is not limited to:

• iron lungs, ventilators, oxygen tanks, regulators and tents including portable oxygen equipment;
• hospital beds;
• wheelchairs including power chairs, customized chairs and power operated
• vehicles, such as triwheelers when considered appropriate;
• crutches or walkers;
• heart pacemakers;
• infusion pumps; and
• whirlpool baths.

42 U.S.C. 1395x(n) Medicare Coverage Issues Manual § 60-9. Medicare will also pay for institutional dialysis services and supplies and home dialysis supplies and equipment. 42 U.S.C. 1395x(s).

Items such as hospital beds and wheelchairs are presumptively medical in nature. Medicare Carriers Manual § 2100.1. Equipment which is generally used for nonmedical purposes is considered presumptively nonmedical, for which Medicare will not pay. This is true even though the item has some medically related use. For example, an air filter may be useful for a patient with severe allergies and an air conditioner may be necessary for a patient who has difficultly controlling internal body temperature but neither is considered medical equipment by Medicare because the primary and customary use of a filter or an air conditioner is a nonmedical one. Medicare Carriers Manual § 2100.1

Some items which Medicare will not provide include: all environmental control devices including items such as air filters and humidifiers (not medical in nature); augmentative and assistive communication devices (convenience items, not primarily medical in nature); bathtub lifts (convenience items); brailers and braille texts (educational in nature); all exercise equipment (not primarily medical in nature); eyeglasses and contacts, except one pair subsequent to cataract surgery; and adaptive telephone arms (convenience item, not medical in nature). Medicare Coverage Issues Manual § 60-9.

Obviously, many of these items do perform a medical function in assisting an individual to overcome the impact of a disability. Some would be purchased by Medi-Cal as medically necessary. In some instances, it may be warranted to request an administrative hearing to challenge a denial. Strong advocacy has resulted in the purchase of items which a carrier or Medicare initially determined to be nonmedical in nature. In one case, Medicare approved a computer to assist a stroke victim to communicate. The man could not speak or write legibly. The Medicare Appeals Council found the computer to be a prosthetic device that replaced the injured portion of his brain.

A few special exception items may be covered by the program even though they do not primarily now serve a medical purpose because they are useful in the absence of illness or disability. These include gel pads and pressure and water mattresses when prescribed for patients susceptible to bedsores and heat lamps where a medical need for heat therapy is established. Medicare Carriers Manual § 21001.1

Medical equipment must be determined to be medically necessary. It must be expected to make a meaningful contribution to the treatment of the patient's illness or disability. There must be a prescription and other information which establishes the necessity for the device. Medicare Carriers Manual § 2100.2.

Separate justification must be provided for any add-on items for durable medical equipment. For example, if positioning devices or pads are necessary add-on equipment for a custom made wheelchair to prevent the development of pressure sores, the physician's description of the beneficiary's condition must include the likelihood of development of such a condition and recommend the equipment necessary to prevent it. Medicare Carrier's Manual § 2100.2.

Even though durable medical equipment may be necessary, it must also be determined to be reasonable. To determine this, the carrier considers: owhether the expense of the item to the program would be clearly disproportionate to the therapeutic benefit;

• whether the item is substantially more costly than other medically appropriate and realistically feasible care; and
• whether the item serves the same purpose as equipment already available to the beneficiary.

In the event that a less expensive appropriate alternative device is found, payment will be limited to the reasonable charge for that device.

The key to submitting a successful Medicare claim is good medical documentation of medical necessity and reasonableness. Physician's and suppliers must provide detailed reports which establish the beneficiary's diagnosis, prognosis and the nature and extent of functional limitations, therapeutic interventions that have been attempted in the past and the results, and past experience with the suggested item. The physician must establish that the requested equipment is medically necessary, is part of the beneficiary's course of treatment, the potential functional outcome, and that no less expensive appropriate equipment is available. It is often necessary for physicians and suppliers to have a dialogue with carriers concerning the beneficiary's need for the service and any guidelines the carrier will apply in making a decision. Physicians and suppliers are responsible for completing and submitting the proper forms to the Social Security office.