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Items Covered by Insurance

Medicaid is a Payer of last resort, they will cover most items. Any items not covered can be submitted to Medicaid for prior authorization.

 

Medicare will cover all equipment and supplies except for:

 

  •      Bathroom Equipment

  •      Overbed Table

  •      Incontinent Supplies

  •      Pulse Oximeter

  •      Enteral Formula by Mouth

 

In addition, if a patient is going on service with a home care agency (PPS) the patients wound care and ostomy care must be billed to the home care agency.

 

Medicare HMO’s as well as commercial insurance companies, will normally follow the Medicare guidelines as well.

 

The following commonly requested items are not covered:

 

  •      Hip Kits

  •      Hip Chairs

  •      Stair Lift

  •      Geri Chair

  •      Shower Hose

  •      Ramps

                                                                                                          

Hoyer Lifts

 

A patient Hoyer lift is covered if transfer between bed and chair, wheelchair, or commode is required and without the use if a lift the patient would be confined.

 

Hoyer lifts have different sling options. The basic is a half body sling, we also carry fully body slings as well as full body slings with commode opening.

 

Nebulizers

 

Nebulizers are covered to administer bronchodilators for obstructive pulmonary disease. Metered dose inhalers and spacers have been considered but do not meet the patient’s needs.

 

Commodes

 

A commode is covered when the patient is physically incapable of utilizing regular bathroom facilities.

 

An extra wide/heavy duty commode is covered for a patient who weighs 300 pounds or more.

 

A commode chair with drop down arms is covered if the detachable arms feature is necessary to facilitate transferring the patient or if the patient has a body configuration that requires extra width.

 

Hospital Beds

 

A fixed height hospital bed is covered if one or more of the following criteria (1-4) are met:

 

  1. The patient has 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.

 

  1. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain.

 

  1. The patient requires the head of the bead to be elevated more the 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease or problems with aspiration. Pillows and wedges must have been considered and ruled out.

 

  1. The patient requires traction equipment, which can only be attached to a hospital bed.

 

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

 

A heavy duty extra wide hospital bed is covered if the patient meets one of the criteria for a fixed height hospital bed and the patient’s weight is more than 350 pounds, but does not exceed 600 pounds.

 

A extra heavy duty hospital bed is covered if the patient meets one of the criteria for a hospital bed and the patients weight exceeds 600 pounds.

 

A total electric hospital bed is not covered, the height adjustment feature is only for convenience.

 

Medicaid will pay for a full electric hospital bed, however Medicaid must be the only payer otherwise the rules for primary insurance apply. A patient can privately upgrade to a full electric bed for $200.00.

                     

Canes | Crutch

 

Impaired ambulation.

 

Walkers

 

A standard walker and related accessories are covered if all of the following criteria are met:

 

  1. The patient has a mobility limitation that significantly impairs their ability to participate in one or more mobility related activities of daily living in the home. AND

 

  1.  The patient is able to safely use the walker. AND

 

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

A wheelchair can be ordered in combination with a walker for training or physical therapy purposes.

 

Enteral Feeding

 

Enteral supplements are only covered by Medicaid. Medicare will only cover if it is the patient’s sole means of nutrition. If formula is being ordered for use orally a prior authorization has to be obtained from Medicaid by the doctor and given to us, so we can dispense.

 

If the patient is being fed via G-tube we can bill all insurances. We must have a physicians order informing us the formula needed and the daily caloric intake. The patient can be feed via pump, syringe (bolus) or gravity bags.

 

Group II Support (Alternating Air Mattress)

 

Patients must have two stage II ulcers on their trunk or pelvis and patient has to have been on group I support surface for at least thirty days prior to qualifying for an air mattress, or one stage III or IIII.

 

Questions to ask:

  1. If a bed is being ordered:

  • Is the patient completely immobile?

  • Does the patient have limited mobility?

  • Does the patient have pressure ulcers on the trunk or pelvis?

  • Does the patient have impaired nutritional status?

  • Does the patient have fecal or urinary incontinence?

  • Does the patient have altered sensory perception?

  • Does the patient have comprised circulatory status?

If so patient should receive a group one support surface (i.e. gel overlay)

Does the patient have Medicaid: if yes, then the patient can benefit from an over the bed table.

 

  1. If oxygen is being ordered

  • Does the patient have an O2 saturation level below 89%

  • Was a prescription written to include liter flow and O2 sat on room air

 

Does the patient have Medicaid: if yes, can the patient benefit from a pulse oximeter to help them monitor the saturation level at home?

 

  1. If suction pump is being ordered

  • Does the patient have a Tracheostomy: if so what size suction catheter does the patient need?

  • If not, does the patient need oral suctioning and why?

 

  1. If CPAP is being ordered

  • Do you have a copy of the sleep study?

 

  1. If BIPAP is being ordered

  • Has a CPAP been tried and ruled out?

 

  1. If feeding supplies are being ordered

  • How is the patient fed, via pump, syringe or gravity?

  • Do you have a prescription with the formula needed and caloric intake per day?

 

Manual Wheelchairs

 

A manual wheelchair is covered if:

The patient has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, or bathing either:

 

  •  Entirely limited

  •  Can accomplish but with no risk to safety

  •  Can accomplish but not within a reasonable time

 

In addition, does the patient have sufficient upper extremity and/or lower extremity strength or the endurance needed to self propel an optimally configured manual wheelchair?

 

Does the patient have a caregiver who is willing and able to provide assistance with the wheelchair?

 

Power Mobility Device

 

In order for Medicaid to cover a motorized wheelchair or scooter we must have the 13 page Wheelchair and Seating Assessment Guide completed by a PT or OT and a prescription from the doctor. The paperwork is then submitted to Medicaid and can take upwards of six weeks for an approval.

 

Medicare requires we have a Face to Face Mobility Examination report completed and a prescription from the doctor. In addition we will need chart notes from the doctor before we can determine if the patient qualifies for a power mobility device. It must all complete the Medicare requires 7 elements*. The paper will then be submitted to Medicare and it can take upwards of six weeks for approval.

                                                                                   

The Seven Elements * 

 

  1. The Name of the Beneficiary. (The patient) àShould be on the Script, face to face, and Doctor Notes.

  2. Item being ordered. àShould be on the Script, face to face, and Doctor Notes.

  3. The date the face to face eval was done. àShould be on the face to face

  4. The Dx and reasons for the need of the item. àDx should be on the Script, face to face, and Doctor Notes.

  5. Length of need à Should be on script

  6. Doctors Signature àShould be on the Script, face to face, and Doctor Notes.

  7. Date of Doctors Signature. àShould be on the Script, face to face, and Doctor Notes.

 

Commercial insurances and HMO’s vary on their coverage criteria. Once we receive the order we can submit it to the insurance for authorization and they will advise us, as to what additional information is required.

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