Getting Medically Necessary Equipment Through Medicare

Part 3, Chapter 9: Medicare and Medicare Related Programs: Medicare Page 5

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Although most Medicare: Part B claims are generally processed through a specific local plan administrator, claims for durable medical equipment -- manual and power wheelchairs, crutches, hospital beds, and other equipment -- are usually processed through a completely separate Medicare regional administrator.

Such claims may be subject to different rules and procedures, both in comparison with other Medicare claims and with similar claims processed under private insurance policies. For example, Medicare's definition of medical necessity may differ from the definition used in many private insurance policies.

In general, to qualify for Medicare coverage for medical equipment, the equipment must be needed for use within the home. Thus, an individual with severe arthritis who can walk short distances but who may need a power wheelchair for longer distances outside of the house might not qualify for coverage for the wheelchair under Medicare's definition of medical necessity. However, an individual with the same disability might meet the definition of medical necessity used by many private insurance policies. Thus, although the power wheelchair might not be covered by Medicare, it might be covered by such policies. (See Chapter 10 for a discussion of how the application of Medicare's definition of medical necessity for a power wheelchair might affect coverage under a Medigap policy or under an employer-sponsored group health insurance policy that continues after retirement and that acts as a Medicare supplement.)

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