Understanding Insurance Guidelines for Durable Medical Equipment & Supplies

HELPFUL INFORMATION FOR FILLING OUT DOCUMENTATION FOR OXYGEN

Initial coverage for home oxygen therapy and oxygen equipment is reasonable and necessary for Groups I and II if all of the following conditions are met.

    1.  The treating physician has ordered and evaluated the results of a qualifying blood gas study 

           performed at the time of need; AND

    2.  The patient’s blood gas study meets the criteria stated below; AND

    3.  The qualifying blood gas study was performed by a treating physician or by a qualified 

           provider or supplier of laboratory services; AND

    4.  The provisions of oxygen and oxygen equipment in the home setting will improve the 

           patient’s condition.

Medicare Qualifications

  Group I criteria include any of the following:

1. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below

88% taken at rest (awake) on Room Air.

2. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below

88% 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% while awake.  In this instance

Oxygen and oxygen equipment is only reasonable and necessary during sleep, OR

     3.    A decrease in arterial PO2 more than 10 mm HG, or a decrease in arterial oxygen saturation

             more than 5 percent from the baseline saturation, taken during sleep and associated with 

             symptoms of hypoxemia such as impairment of cognitive processes and nocturnal restlessness

             or insomnia (not all inclusive).  In this instance, oxygen and oxygen equipment is only

              during sleep; OR

      4.   An arterial PO2 at or below mm Hg or an arterial oxygen saturation at or below 88 percent, 

             taken during exercise 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 instance,

              the portable oxygen and oxygen equipment is only reasonable and necessary while awake and

              exercise.

When oxygen therapy and oxygen equipment is covered based on an oximetry study obtained during exercise, there must be documentation of three (3) oximetry studies in the patient’s medical record:

   1.  Testing at rest without oxygen; AND

   2.  Testing during exercise without oxygen; AND 

   3.  Testing during exercise and with oxygen applied (to demonstrate the improvement of the hypoxemia)

All 3 test must be performed within the same testing session.  Exercise testing must be performed in-person by a treating physician or other medical professional qualified to conduct exercise oximetry testing

   Group II criteria include any of the following:

      A.  An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent; AND

      B.  Any of the following:

             1.  Dependent edema suggesting congestive heart failure; OR

             2.  Pulmonary hypertension or co pulmonale, determined by measure of pulmonary artery

                   Pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on EKG (P wave greater

                   than 3 mm in standard leads II, III, or AVF); OR

              3.  Erythrocythemia with a hematocrit greater than 56 percent.

Liter flow greater than 4 lpm:

A copy of a blood gas study showing blood gas levels in the Group I or Group II range while the patient was on oxygen at the rate of 4 LPM

FACE TO FACE NOTES

The face-to-face evaluation must indicate the medical necessity of the equipment ordered because the DME supplier must have the documentation on file as to why the patient is needing the equipment ordered.  Test results may also be documented in the notes.

The face-to-face notes may be performed by the physician, NP, PA or CSN.

PLEASE NOTE:  If the face-to-face is being performed by someone other than the physician, it MUST be approved and signed by the physician upon completion.

HELPFUL INFORMATION FOR FILLING OUT DOCUMENTATION FOR ROLLING WALKER/WALKER

Here is the criteria Medicare has for these items listed below.  Please see that the patient meets the criteria and that it is all documented in the progress notes/Face to Face notes.  Below you will see what Medicare is basically wanting and looking for in the documentation that is submitted.

Medicare Qualifications

1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.

A mobility limitation is one that:

a. Prevents the beneficiary from accomplishing the MRADL entirely, OR

b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform the MRADL OR

c. Prevents the beneficiary from completing the MRADL within a reasonable time frame; AND

2. The beneficiary is able to safely use the walker; AND

3. The functional mobility deficit can be sufficiently resolved with use of a walker.

If all of the criteria are not met, the walker will be denied as not reasonable and necessary.

           If your prescription is for a walker, it must be documented why any lower-level item will 

           not suit your need such as a cane or crutch.

FACE TO FACE NOTES

The face-to-face evaluation must indicate the medical necessity of the equipment ordered because the DME supplier must have the documentation on file as to why the patient is needing the equipment ordered.

  The face-to-face notes may be performed by the physician, NP, PA or CSN.

PLEASE NOTE:  If the face-to-face is being performed by someone other than the physician, it MUST be approved and signed by the physician upon completion.

HELPFUL INFORMATION FOR FILLING OUT DOCUMENTATION FOR COMMODE

Here is the criteria Medicare has for these items listed below.  Please see that the patient meets the criteria and that it is all documented in the progress notes/Face to Face notes.  Below you will see what Medicare is basically wanting and looking for in the documentation that is submitted.

Medicare Qualifications

A commode is covered when the beneficiary is physically incapable of utilizing regular toilet facilities, which would occur in the following situations:

• The beneficiary is confined to a single room, OR

• The beneficiary is confined to one level of the residing home and there is no toilet on that level, OR

• The beneficiary is confined to the home and there are no toilet facilities in the home.

 PLEASE NOTE:  

1. Bedside commodes are not covered if they are placed over the toilet in the bathroom

2. Extra wide / heavy duty commode chairs may be covered if the beneficiary weighs 300 pounds or more.

3. A commode chair with detachable arms may be covered if the detachable arms feature is necessary

a. to facilitate transferring the beneficiary, or

b. If the beneficiary has a body configuration that requires extra width.

FACE TO FACE NOTES

The face-to-face evaluation must indicate the medical necessity of the equipment ordered because the DME supplier must have the documentation on file as to why the patient is room-confined or unable to access toilet facilities.  

  The face-to-face notes may be performed by the physician, NP, PA or CSN.

PLEASE NOTE:  If the face-to-face is being performed by someone other than the physician, it MUST be approved and signed by the physician upon completion.

HELPFUL INFORMATION FOR FILLING OUT DOCUMENTATION FOR HOSPITAL BED

Here is the criteria Medicare has for these items listed below.  Please see that the patient meets the criteria and that it is all documented in the progress notes/Face to Face notes.  At the bottom of the, you will see what Medicare is basically wanting and looking for in the documentation that is submitted.

Medicare Qualifications:

Coverage is considered for a fixed-height hospital bed when at least one of the following are met:

• Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed OR

• Patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain OR

• Requires the head of the bed to be elevated more than 30 degrees most of the time because of congestive heart failure, chronic pulmonary disease, or problems with aspiration OR

• Requires traction equipment that can only be attached to a hospital bed.

Coverage is considered for a variable height bed if the beneficiary meets one of the criteria for a fixed height hospital bed AND requires a bed height different than a fixed height hospital bed to permit transfers to a chair, wheelchair or standing position.

Coverage is considered for a semi-electric hospital bed if the beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.

FACE TO FACE NOTES

The face-to-face evaluation must be performed by the physician, NP, PA or CSN.

PLEASE NOTE:  If the face-to-face is being performed by someone other than the physician, it MUST be approved and signed by the physician upon completion.

The evaluating physician must document in the patient’s records the event of the face-to-face encounter.

The documentation in the medical records must include:

• Evaluation of the client

• Assessment of medical necessity

When the physician documents in the medical records, there must be adequate and sufficient evidence present to justify medical necessity. The purpose of the visit must be for the requesting equipment or supplies.

The medical record is not limited to physician's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive)

HELPFUL INFORMATION FOR FILLING OUT DOCUMENTATION FOR PATIENT LIFT

Here is the criteria Medicare has for these items listed below.  Please see that the patient meets the criteria and that it is all documented in the progress notes/Face to Face notes.  At the bottom of the, you will see what Medicare is basically wanting and looking for in the documentation that is submitted.

Medicare Qualifications

• Patient lifts may be covered if the transfer between the bed and a chair, wheelchair or commode requires the assistance of more than one person.

• Without the use of a lift the patient would be bed confined.

• A multi-positional patient transfer system may be covered if BOTH of the following are met:

                The basic coverage criteria for a lift are met; AND

                The beneficiary requires supine positioning for transfers.

FACE TO FACE NOTES

The evaluating physician must document in the patient’s records the event of the face-to-face encounter.

The documentation in the medical records must include:

• Evaluation of the client

• Assessment of medical necessity

The face-to-face evaluation must be performed by the physician, NP, PA or CSN.

PLEASE NOTE:  If the face-to-face is being performed by someone other than the physician, it MUST be approved and signed by the physician upon completion.

HELPFUL INFORMATION FOR FILLING OUT DOCUMENTATION FOR WHEELCHAIRS

Here is the criteria Medicare has for these items listed below.  Please see that the patient meets the criteria and that it is all documented in the progress notes/Face to Face notes.  At the bottom of the, you will see what Medicare is basically wanting and looking for in the documentation that is submitted.

Medicare Qualifications

• STANDARD WHEELCHAIRS (K0001)– MEDICAL RECORDS DOCUMENT ALL OF THE FOLLOWING ARE MET:

o The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home; AND

o The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker; AND

o The patient’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided; AND

o Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in their MRADLs and will get used in the home on a regular basis; AND

o The patient has not expressed an unwillingness to use the wheelchair in the home; AND

o The patient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.  (Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.) OR

o The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair. 

FACE TO FACE NOTES

The face-to-face evaluation must be performed by the physician, NP, PA or CSN.

PLEASE NOTE:  If the face-to-face is being performed by someone other than the physician, it MUST be approved and signed by the physician upon completion.