Did you know that Medicare may cover the rental or purchase of durable medical equipment that you need for use in your home?

Durable medical equipment (DME) is equipment that is primarily and customarily used to serve a medical purpose, can withstand repeated use, and is appropriate for use in the home. Some examples of DME include hospital beds, walkers, wheel chairs and oxygen tents.

Medical supplies of an expendable nature, such as bandages, rubber gloves and irrigating kits are not considered by Medicare to be DME.

Medicare only covers DME if it is necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body member.

Medicare does not routinely cover air conditioners, dehumidifiers, and several other supplies that it considers to be not primarily medical in nature. Though often crucial to a patient's well being, these supplies are considered to be convenience items which may be useful to a beneficiary in the absence of illness or injury. However, coverage for many of these items can be granted by an Administrative Law Judge if your doctor certified they are medically necessary. Be sure to ask your doctor if the DME your doctor has recommended for you is an item normally covered by Medicare.

You must have your doctor prescribe the equipment for you and certify that it is medically necessary in order to get Medicare coverage. Your doctor must complete the DME Medical Necessity form. You may obtain this form from your physician or from your local Medicare office. This form must be submitted to Medicare along with your DME claim. DME suppliers, rather than the beneficiaries, must submit the claims paperwork to Medicare.

Medicare determines the maximum rate it will consider for payment for each piece of DME, known as the "approved amount." Medicare then pays 80% of that approved amount.

Will Medicare pay for the DME all at once?

Medicare will not pay for the purchase of DME valued at over $150 all at once. Instead, Medicare makes monthly rental payments during the period of medical need. These payments usually equal 10% of the purchase price of the DME and may not exceed a period of 15 months. After 15 months of continuous rental, a beneficiary is considered to own the equipment.

Will Medicare pay for the repair and maintenance of DME equipment?

Medicare will pay for the repair of DME to make it serviceable. However, if the repair expense exceeds the expense of purchasing a replacement, Medicare will not pay the excess. Routine periodic servicing of DME is not covered by Medicare.

What if Medicare denies payment for my claim or I disagree with the amount Medicare will pay for my claim?

If Medicare denies payment for you claim or if you are not satisfied with the amount Medicare has approved for your DME, you may request that the Medicare "Carrier" which has made the determination perform a review of its decision. This review request must be made within six months of the date of your Explanation of Medicare Benefits. Make your request by writing to the carrier and include a copy of the Explanation of Medicare Benefits. You should also keep a copy of your review request for your own files.

If you receive an unfavorable review decision, and if more than $100 is "in controversy," you may request a fair hearing with the Medicare Carrier. (The amount in controversy simply means the amount Medicare would have paid you after the coinsurance and deductible amounts had been deducted from your claim.) You may also meet the $100 minimum by combining other claims which have been reviewed and are not past the deadline for appeal. You must request the fair hearing from the Medicare Carrier with six months of the date of your review decision. Again, you should keep a copy of the request for your files.

Yes. There are three types of fair hearings: on-the-record, in person and telephone. You must determine which type is best for your case and most convenient for you. In an on-the-record hearing, the hearing officer will rely on the documents in the

record, and you may submit any additional information. For instance, if coverage for your equipment was denied because it was not considered to be necessary by Medicare, the Medicare Advocacy Project recommends obtaining amore detailed letter from the physician who prescribed the equipment, to further describe why you needed it.

If the on-the-record decision results in a denial of coverage, you may then request either an in-person or telephone fair hearing. The on-the-record decision will explain how to request the hearing. You should review the on-the-record decision carefully to determine why the denial occurred, and to learn if any additional information is needed in order to prepare for the in-person or telephone fair hearing.

If you do not agree with the fair hearing decision and more than $500 is "in controversy," you may request a hearing before an Administrative Law Judge (ALJ) of the Social Security Administration. You must make this request in writing within sixty days of the date of the fair hearing decision. The fair hearing decision will explain your right to request a hearing.

If you do not agree with the ALJ decision, you may ask the Appeals Council of the Social Security Administration to review your case. The hearing decision will explain how to request this review. The Appeals Council, located in Virginia, will decide either to affirm the ALJ's decision, reverse the decision, or return the case to the ALJ to be heard again. After this stage, if you still are not satisfied, and more than $1000 is in controversy, you may appeal your coverage determination to federal court.

Yes. The Medical Advocacy Project highly recommends you take advantage of the appeals process. Coverage for many types of DME is routinely denied at the initial determination stage but often granted after the beneficiary has had an opportunity to offer more information during an appeal. Also, coverage for items which are denied as comfort items or not primarily medical in nature can only be obtained from an ALJ.

It is very helpful to have legal advice even in the early stages of an appeal because laws regarding Medicare coverage for DME are very specific and sometimes confusing. An advocate can review your denial, offer guidance, and, if necessary, represent you in your appeal.

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