Medicare Coverage for Specific Types of Home Medical Equipment

  • BiPaps/Respiratory Assist Devices**

    • For a respiratory assist device to be covered, the treating physician or healthcare provider must fully document in your medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headaches, cognitive dysfunction, dyspnea, etc.
    • A respiratory assist device is covered if you have a clinical disorder characterized as
      • (I) restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities),
      • (II) severe chronic obstructive pulmonary disease (COPD), or
      • (III) central sleep apnea (CSA) or Complex Sleep Apnea (CompSA),
      • (IV) hypoventilation syndrome
    • If you are diagnosed with Obstructive Sleep Apnea, see the coverage criteria for Positive Airway Pressure Devices below.
    • Various tests may need to be performed to establish one of the above diagnosis groups.
    • Three months after starting your therapy you must return to your doctor or healthcare provider for a follow-up to confirm the machine is benefitting you and that you are regularly using the device.
      • This must be documented in your doctor or healthcare provider’s notes from that office visit. Your physician or healthcare provider will be required to respond in writing to questions regarding your continued use along with how well the machine is treating your condition.
      • If you are not using your machine for an average of four hours per night per 24 hour period at the time you meet with your doctor or healthcare provider, then you may be held responsible (via an Advance Beneficiary Notice) to pay for the rental until you meet this requirement.
    • BiLevel Devices are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
    • Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
  • ** Some or all of the products in this category may be subject to competitive bidding depending on where you live.

    Breast Prostheses


    • Breast Prostheses are covered after a radical mastectomy. Medicare will cover:
      • One silicone prosthesis every two years or a mastectomy form every six months.
      • As an alternative, Medicare can cover a nipple prosthesis every three months.
      • Mastectomy bras are covered as needed.
    • There is no coverage for replacement prostheses due to wear and tear before the specified time frames. However, Medicare will cover replacement of these items due to:
      • Loss
      • Irreparable damage, or
      • Change in medical condition (e.g. significant weight gain/loss)
    • You are allowed only one prosthesis per affected side, others will be denied as not medically necessary even if attempting asymmetry (an Advance Beneficiary Notice should be provided in this circumstance).
    • Mastectomy sleeves which are used to control swelling are not covered in the home setting because they do not meet Medicare’s definition of a prosthesis; however, it is possible that they may be covered under the hospital per diem if you request one during your hospital stay.
    • A mastectomy bra is covered if the pocket of the bra is used to hold a covered prosthesis or mastectomy form.
  • Cervical Traction

    • Cervical traction devices are covered only if both of the criteria below are met:
      1. The patient has a musculoskeletal or neurologic impairment requiring traction equipment.
      2. The appropriate use of a home cervical traction device has been demonstrated to the patient and the patient tolerated the selected device.
  • Commodes**

    • A commode is only covered when you are physically incapable of utilizing regular toilet facilities. For example:
  • 1.You are confined to a single room, or
    2.You are confined to one level of the home environment and there is no toilet on that level, or
    3.You are confined to the home and there are no toilet facilities in the home.

    • Heavy-duty commodes are covered if you weigh over 300 pounds.
    • Commodes with detachable arms are covered if your body configuration requires extra width, or if the arms are needed to transfer in and out of the chair.
  • ** Some or all of the products in this category may be subject to competitive bidding depending on where you live.

    Compression stockings

    • Gradient compression stockings worn below the knee are covered only when used for the treatment of open venous stasis ulcers. They are not covered for the prevention of ulcers, prevention of the re-occurrence of ulcers, or treatment of lymphedema or swelling without ulcers.
  • Positive Airway Pressure Devices (CPAPs and Bi-Level Devices for Obstructive Sleep Apnea)**

    Continuous Positive Airway Pressure (CPAP) Devices are covered only if you have Obstructive Sleep Apnea (OSA).

    • Medicare requires that you first meet with your physician or healthcare provider to discuss your symptoms and risk factors for Obstructive Sleep Apnea.
    • After meeting with your doctor or healthcare provider, you must then have an overnight sleep study performed in a sleep laboratory or through a special, in-home sleep test to establish a qualifying diagnosis of Obstructive Sleep Apnea.
    • Your doctor or healthcare provider may then prescribe a CPAP to treat your obstructive sleep apnea. Medicare will initially cover a three month trial of this equipment. Medicare will also pay for replacement masks, tubing and other necessary supplies as prescribed by your doctor or healthcare provider.
    • If during your sleep study (or during your trial period) the CPAP device is not working for you, or if you cannot tolerate the CPAP machine, your doctor or healthcare provider may prescribe a different device called a Bi-Level or a Respiratory Assist Device, and Medicare can consider this for coverage as well.
    • After the first three months of use, you will be required to verify if you are benefiting from using the device and how many hours a day you are using the machine. Per Medicare, a follow-up face-to-face visit with your physician or healthcare provider is required to document an improvement of your symptoms no sooner than 31 days and no later than 91 days from the set-up date. Data is typically downloaded from your sleep equipment and must be provided to your doctor or healthcare provider during this follow-up visit to document that the machine has been used consistently for at least 4 hours per night on 70% of nights during a 30-day consecutive period.
    • Talk with your supplier if you are having problems adjusting to the therapy or using the equipment every night. There are a lot of variations that can make the therapy more comfortable for you.
    • CPAPs and Bi-Levels are considered capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
    • Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
  • ** Some or all of the products in this category may be subject to competitive bidding depending on where you live.

    Diabetic Supplies**

    • For diabetics, Medicare covers the glucose monitor, lancets, spring-powered lancing devices, test strips, control solution and replacement batteries for the meter.
    • Medicare does not cover insulin injections or diabetic pills unless covered through a Medicare Part D benefit plan.
    • Diabetics can obtain up to a three month supply of testing materials at a time.
    • Medicare will approve up to one test per day for non-insulin dependent diabetics and three tests per day for insulin-dependent diabetics without additional verification of need.
      • If you test above these guidelines, you are required to be seen and evaluated by your physician or healthcare provider within six months prior to receiving your initial supplies from your supplier.
      • In addition, you must send your supplier evidence of compliant testing (e.g. a testing log or notes from your physician) every six months to continue getting refills at the higher levels.
    • If at any time your testing frequency changes, your physician or healthcare provider will need to give your supplier a new prescription.
    • As of July of 2013, Medicare began a national mail order program that requires you to get your diabetic supplies through one of approximately 20, nationally contracted suppliers for all testing supplies delivered to your home.
    • Your supplier may not be able to deliver your glucometer to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
  • ** Some or all of the products in this category may be subject to competitive bidding depending on where you live.


    Glasses

    • Medicare covers one complete pair of glasses, after the last cataract surgery with intra-ocular lens replacement. The Medicare benefit includes a frame and two lenses. As an alternative a pair of contact lenses can be covered in lieu of glasses.
    • Medicare beneficiaries that have a condition called aphakia (patients who born without an intra-ocular lens, or who have had the lens removed and not replaced), Medicare will cover glasses, and/or contacts as often as is medically necessary.
    • When specifically prescribed for a medical condition documented in your medical chart, Medicare may also cover tint, anti-reflective coating, and/or UV.

  • Hospital Beds**

    • A hospital bed is covered if you have visited your doctor or healthcare provider and during an office visit your doctor or healthcare provider documents in your chart that one or more of the following criteria (1-4) are met:
  • 1.You have 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.You require positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or

    3.You require 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 considered and ruled out, or

    4.You require traction equipment which can only be attached to a hospital bed.

    • Specialty beds that allow the height of the bed to be adjusted are covered if you require this feature to permit transfers to a chair, wheelchair or standing position.
    • A semi-electric bed is covered if your medical condition requires frequent changes in body position and/or you have an immediate need for a change in body position.
    • Heavy-duty/extra-wide beds can be covered if you weigh over 350 pounds.
    • The total electric bed is not covered because it is considered a convenience feature. If you prefer to have the total electric feature, your supplier usually can apply the cost of the qualifying hospital bed toward the monthly rental price of the total electric model. You will need to sign an Advance Beneficiary Notice (ABN) and will be responsible to pay the difference in the retail charges between the two items every month.
    • Hospital beds are a capped rental item, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
    • Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
  • ** Some or all of the products in this category may be subject to competitive bidding depending on where you live.


    Lymphedema Pumps

    Lymphedema Pumps are covered for treatment of true lymphedema as a result of:

    Primary Lymphedema resulting from a congenital abnormality of lymphatic drainage or Milroy’s disease. (This is a relatively uncommon, chronic condition), or

    Secondary lymphedema is much more common and results from the destruction of or damage to formerly functioning lymphatic channels such as:

    radical surgical procedures with removal of regional groups of lymph nodes (for example, after radical mastectomy)

    post-radiation fibrosis

    spread of malignant tumors to regional lymph nodes with lymphatic obstruction,

    or other causes

    Before you can be prescribed a pump, your physician or healthcare provider must monitor you during a minimum, four-week trial period where other treatment options must be tried including limb elevation, exercise and compression garments or bandage systems. If, at the end of the trial, there is little or no improvement from these options, a lymphedema pump can be considered.

    The doctor or healthcare provider must then document an initial treatment with a pump and establish that the treatment can be tolerated.

    Lymphedema pumps also are covered for the treatment of chronic venous insufficiency (CVI) with venous stasis ulcers in the lower extremities (e.g. legs and feet).

    Before you can be prescribed a pump for this condition, your physician or healthcare provider must monitor you during a minimum, six month trial period where other treatment options are tried such as limb elevation, exercise and compression garments or bandage systems. If at the end of the trial, one or more of the stasis ulcers are still present, a lymphedema pump can be considered.

    The doctor or healthcare provider must then document an initial treatment with a pump and establish that the treatment can be tolerated, that there is a caregiver available to assist with the treatment in the home, and then the doctor or healthcare provider must prescribe the pressures, frequency, and duration of prescribed use.

    Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

    • Medicare-covered drugs (other than Medicare Part D coverage)

      • As of February, 2001, all providers of Medicare-covered drugs are required to accept assignment on these items.
      • Traditional Medicare Part B insurance will cover some nebulizer drugs, some infused drugs using a pump, specific immunosuppressive drugs, select oral anti-cancer medications and most parenteral nutrition.
      • The Medicare Part D plans may provide additional coverage of other oral medications, inhalers and similar drugs.
    • Mobility Products: Canes, Walkers, Wheelchairs, and Scooters

      • Essentially the new Mobility Assistive Equipment regulations will ensure that Medicare funds are used to pay for:
        • Mobility needs for daily activities within the home
        • Least costly alternative/lowest level of equipment to accomplish these tasks.
        • Most medically appropriate equipment (to meet the needs, not the wants)
      • Medicare requires that your physician and provider evaluate your needs and expected use of the mobility product you will qualify for.
      • They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions:
        • Will a cane or crutches allow you to perform these activities in the home?
        • If not, will a walker allow you to accomplish these activities in the home?
        • If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home?
        • If not, will a scooter allow you to accomplish these activities in the home?
        • If not, will a power chair allow you to accomplish these activities in the home?
      • Keep in mind if you have another higher level product in mind that will allow you to do more beyond the confines of the home setting, you can discuss with your provider the option to upgrade to a higher level or more comfortable product by paying an additional out of pocket fee using the Advance Beneficiary Notice (ABN) to select the product you like best.
      • A face-to-face examination with your physician is required prior to the initial setup of a power chair or scooter.
      • Your home must be evaluated to ensure it will accommodate the use of any mobility product.
    • Nebulizers

      • Nebulizer machines, medications, and related accessories are usually covered for patients with obstructive pulmonary disease, but can also be covered to deliver specific medications to patients with HIV, CF, brochiectasis, pneumocystosis, complications of organ transplants, or for persistent thick or tenacious pulmonary secretions./
      • Patients can obtain up to a three month’s supply of nebulizer medications and accessories at a time.
    • Non-covered items (partial listing):

      • Adult diapers
      • Bathroom safety equipment
      • Hearing aids
      • Syringes/needles
      • Van lifts or ramps
      • Exercise equipment
      • Humidifiers/Air Purifiers
      • Raised toilet seats
      • Massage devices
      • Stair lifts
      • Emergency communicators
      • Low Vision aids
      • Grab bars
    • Orthopedic Shoes

      • Orthopedic shoes are covered when it is necessary to attach the shoe(s) to a leg brace.
      • However, Medicare will only pay for the shoe(s) attached to the leg braces.
      • Medicare will not pay for matching shoes or for shoes that are needed for purposes other than for diabetes or leg braces.
    • Ostomy Supplies

      • Ostomy supplies are covered for people with a:

        • colostomy
        • ileostomy
        • urostomy
      • Patients can obtain up to a three month’s supply of wafers, pouches, paste, and other necessary items at a time.
    • Oxygen

      • Covered for patients with significant hypoxemia in the chronic stable state when:
        • patient has a chronic lung condition or disease or hypoxemia that might be expected to improve with oxygen therapy, and
        • patient’s blood gas levels or oxygen saturation levels indicate the need for oxygen therapy, and
        • alternative treatments have been tried or deemed clinically ineffective.
      • Categories/Groups are based on the test results to measure your oxygen:
        • I 55≤ mmHg, or 88%≤ saturation
        • For these results you must return to your physician 12 months after the initial visit to continue therapy for lifetime or until the need is expected to end. Typically, you will not have to be retested when you return to your physician for the follow-up visit
        • .
        • II 56-59 mmHg, or 89% saturation
        • For these results, you must be retested within 3 months of the first test to continue therapy for lifetime or until the need is expected to end.
        • III ≥60 or ≥90% not medically necessary.
          Oxygen will be paid as a rental for the first 36 months. After that time if you still need the equipment Medicare will no longer make rental payments on the equipment. If your deductible and copays are met, the equipment title will transfer to you. Medicare will then pay for refilling your oxygen cylinders and for repairs and service of your equipment. Medicare will also separately pay for oxygen accessories such as tubing, masks, and cannulas after the purchase price has been met.
  • Parenteral and enteral therapy



        • Parenteral therapy requires all or part of the gastrointestinal tract be missing. Nutritional formulas are delivered through a vein.
        • Enteral therapy is covered for patients who cannot swallow or take food orally. Nutrition must be delivered through a tube directly into the gastrointestinal tract.
        • Medicare will not pay for nutritional formulas that are taken orally.
      • Patient Lifts

        • A lift 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.
        • An electric lift mechanism is not covered because it is considered a convenience feature. If you prefer to have the electric mechanism, your provider can usually apply the cost of the manual lift toward the purchase price of the electric model by using an Advance Beneficiary Notice (ABN). You would be responsible to pay the difference in the retail charges between the two items.
      • Seat Lift Mechanisms

        • In order for Medicare to pay for a seat lift mechanism, patients must be suffering from severe arthritis of the hip or knee, or have a severe neuromuscular disease. In addition they must be completely incapable of standing up from any chair, but once standing they can walk either independently or with the aid of a walker or cane. The physician must believe that the mechanism will improve, slow down, or stop the deterioration of the patient’s condition.
        • Transferring directly into a wheelchair will prevent Medicare from paying for the device.
        • Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.
      • Support Surfaces

        • Group 1 products are designed to be placed on top of a standard hospital or home mattress. They can utilize gel, foam, water, or air, and are covered for patients who are:
          • Completely immobile OR
          • Have limited mobility with any stage ulcer on the trunk or pelvis (and one of the following):
            • impaired nutritional status
            • fecal or urinary incontinence
            • altered sensory perception
            • compromised circulatory status
        • Group 2 products take many forms, but are typically powered pressure reducing mattresses or overlays. They are covered for patients with one of three conditions:
          • 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, and at the close of that month, the ulcers worsened or remained the same. (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR
          • Large or multiple Stage III or IV ulcers on the trunk or pelvis (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR
          • A recent myocutaneous flap or skin graft for an ulcer on the trunk or pelvis within the last 60 days who were immediately placed on Group 2 or 3 support surface prior to discharge from the hospital and the patient has been discharged within last 30 days.
      • TENS Units

        • TENS units are covered for the treatment of chronic intractable pain that has been present for at least three months or more, and in some cases for acute post-operative pain.
        • Not all types of pains can be treated with a TENS unit. TENS units have proven ineffective in treating headaches, visceral abdominal pains, pelvic pains, and TMJ pains, and therefore Medicare will not pay for the device when used to treat these conditions.
        • For chronic pain sufferers, Medicare will pay for a one or two month trial rental to determine if this device will alleviate the chronic pain. You must return to your physician exactly 30-60 days after initial evaluation to authorize the purchase of this equipment.
        • For acute post-operative pain sufferers, Medicare will consider rental payment for a maximum of 30 days. Any duration longer than that will require individual consideration.
      • Therapeutic Shoes

        • Special therapeutic shoes, inserts, and modifications can be covered for diabetic patients with the following foot conditions:

          • previous amputation of a foot or partial foot
          • history of foot ulceration
          • peripheral neuropathy with callus formation
          • foot deformity
          • poor circulation in either foot
      • Urological Supplies

        • Urinary catheters and external urinary collection devices are covered to drain or collect urine for a patient who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months.