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Durable Medical Equipment: Do You Need Pre-authorization?

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As a Medicare beneficiary, your Medicare Part B coverage may help to pay for covered durable medical equipment. However, you may have to meet certain requirements, such as pre-authorization, before your benefits kick in. Here’s what you need to know about durable medical equipment pre-authorization and your Medicare coverage.

What is durable medical equipment?

According to Medicare.gov, durable medical equipment (DME) is equipment that tolerates repeated use, serves a particular health care purpose, and is primarily useful only to a person with a specific illness or injury. Durable medical equipment includes wheelchairs, hospital beds, blood sugar monitors, oxygen equipment, and walkers or canes, for example. Items that have an expected lifetime of less than three years, such as catheters and bandages, are generally not considered durable medical equipment.

In addition, to meet the Medicare criteria for durable medical equipment, the item must be medical in nature, and not something that would also benefit a person without a specific medical condition. For example, if your doctor suggests that an electric air cleaner would be helpful in reducing asthma attacks, the air cleaner might not be considered durable medical equipment under Medicare rules because it is also something that a person without asthma might use to maintain a comfortable environment in the home.

Most health care providers who participate with Medicare know what qualifies as durable medical equipment under Medicare guidelines, so if you are concerned about paying for a particular piece of equipment your doctor recommends, be sure to ask your doctor how Medicare treats the equipment and whether pre-authorization is required. Generally speaking, your health care provider must write a prescription for DME before Medicare will consider covering it; a verbal recommendation doesn’t count for Medicare payment purposes.

What is pre-authorization?

The Centers for Medicare and Medicaid Services defines pre-authorization as the process through which a Medicare beneficiary gets provisional approval for coverage before the DME supplier submits a claim to Medicare for the equipment your doctor prescribed.

The purpose behind pre-authorization is to make sure you get the equipment you need quickly, without unnecessary paperwork delays and appeals, and to give you peace of mind that your equipment will be covered by Medicare.

When do I need pre-authorization for durable medical equipment?

Medicare is phasing in a pre-authorization process for certain types of durable medical equipment. Currently, the pre-authorization process only applies to power wheelchairs and hyperbaric oxygen, although other pieces of durable medical equipment may be added to the list of products requiring pre-authorization.

It’s also important to note that in some locations, durable medical equipment is subject to Medicare’s competitive bidding program, which is basically a cost-control measure that requires Medicare beneficiaries to get their DME from a supplier approved by, and contracted with, Medicare.

If your doctor prescribes durable medical equipment to treat your injury or illness, he or she should know whether or not the particular piece of equipment requires pre-authorization or is subject to the competitive bidding program. If pre-authorization is required, your doctor’s staff usually handles any paperwork or certification requirements to get Medicare approval for the equipment you need. You, as the Medicare beneficiary, are generally not responsible for securing pre-authorization for your DME.

 

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