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Useful Info

How do I obtain Medicare coverage for medical equipment I need in the home?

The first step is for your physician to prescribe the item. Once you have the initial prescription you can contact us for coverage. If the item is a Medicare benefit we will obtain additional paperwork required by Medicare from your physician.

Who initiates the necessary paperwork?

We do. We forward the Certificate of Medical Necessity (CMN) or Written Confirmation of Verbal Order (WCVO) to the physician. The physician completes these forms and returns them to us.

What do we need to begin processing your Medicare claim?

  • You can fax or email us the following information:
  • Full legal name of patient, address, phone number.
  • Full legal name of patient, address, phone number.
  • Full name, Telephone and fax number of prescribing doctor
  • Doctor's prescription for desired equipment, which must include patient's diagnosis.
  • Patient's Medicare number, which must include the alpha character after the number (A, B, D, etc).
  • Supplemental insurance information, if any.
  • Patient's date of birth.
  • Patient's height & weight.

What is Covered by Medicare?

  • Medicare Part B helps pay for durable medical equipment, including:
  • Full legal name of patient, address, phone number.
  • Manual wheelchairs (capped rental item)
  • Power wheelchairs
  • Some positioning devices such as seat and back cushion (diagnosis driven)
  • Walkers, canes, crutches
  • Scooters
  • Seat-lift mechanisms for lift-chairs, patient lifts
  • Hospital beds, gel overlays and air mattresses (capped rental item)
  • Oxygen equipment

What is a capped rental item?

Medicare considers hospital beds, manual wheelchairs, air mattresses, as capped rental items. This means that Medicare pays for 13 months rental after which the equipment will become the patients. You must use a vendor that rents equipment and bills Medicare for the monthly payments in your area. We do not rent equipment over the Internet and do not bill Medicare for this type equipment on Internet sales. We advise you to seek a local dealer that rents since Medicare will require them to install and maintain this "capped rental" equipment. If you live in our local area please contact us for capped rental equipment.

What is NOT covered by Medicare?

Equipment not covered by Medicare includes; adaptive daily living aids such as: reachers, sock-aids, utensils, bathroom equipment, incontinence supplies, compression socks. For more detailed information regarding coverage, call 1-800-MEDICARE.

Does Medicare cover for items to be used in Nursing Home?

Home medical equipment must be appropriate for use in the home. Your "home" is your house, (including assisted living), apartment, a relative's home, a home for the aged, or some other type of institution in which you live. However, an institution IS NOT CONSIDERED YOUR HOME if it is: a hospital or primarily engaged in providing skilled or non skilled nursing care (this does not apply to certain supplies and equipment that are prosthetics, orthotics, and medical supplies).

Are walkers and rollators covered?

Medicare will allow a walker/rollator every 5 years. They cover 80% of the allowed amount set by Medicare. This is usually about $130.00. Regardless of whether your rollator cost $150 or $350, the reimbursement amount is the same. Patient is responsible for the difference between what Medicare pays and the cost of the rollator.

Does Medicare cover Lift Chairs?

  • Only the seat lift mechanism on a lift chair could be considered medically necessary if all of the following coverage criteria are met:
  • The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
  • The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient's condition.
  • The patient must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
  • Once standing, the patient must have the ability to ambulate (walk).

Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the patient, and effectively assist a patient in standing up and sitting down without other assistance. Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-like motion and jolts the patient from a seated to a standing position. Coverage is limited to the seat lift mechanism, even if it is incorporated into a chair.

Does Medicare cover Wheelchair Lifts and Ramps?

Medicare does not reimburse nor authorize the purchase of a lift for a wheelchair or scooter at this time. Such items are typically not considered a medical necessity because they can also be used by persons without a medical condition. Don't forget, Medicare covers items needed "inside" the residence.

Do I have to pay the 20% co-payment to Medicare?

After you have met your deductible, you're still responsible for paying directly, or through supplemental insurance, at least 20 percent of the Medicare approved amount. This co-payment may not be dropped by the supplier except in hardship situations and only on a case-by-case basis.

Medicare Eligibility Information

1. Canes & Crutches

Medicare pays for single point as well as quad cane and underarm and forearm crutches. To qualify for payment we simply need a prescription from your doctor. Since Medicare pays only for least costly equipment, you may have to pay the difference between the cost of the item and Medicare allowable.

2. Walkers & Rollators

Medicare pays for walkers with our without wheels if a patient 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; the patient is able to safely use the walker and the functional mobility deficit can be sufficiently resolved with use of a walker. A heavy duty walker is covered for patients who meet coverage criteria for a standard walker and who weigh more than 300 pounds.

Medicare pays for Rollators up to $130 (keep in mind that Medicare pays 80% of allowable, 20% must be paid by patient or secondary payer). The difference between the cost of the Rollator and Medicare paid amount is patient’s responsibility. Please note that if you have received a regular walker from Medicare and now need a Rollator, Medicare will not pay for it because it will be considered same or similar equipment and change in condition will not justify the new equipment.

The U Step walker will be reimbursed if the patient has a neurological disorder or other condition restricting the use of one hand.

Knee walkers or walker accessories are not covered by Medicare.

3. Manual Wheelchairs

Medicare pays for standard/lightweight manual wheelchairs and transport wheelchairs on a capped rental basis. This means that the equipment is rental 13 months and is the property of Sherman Oaks Medical Supplies and must be returned to us if the patient is no longer in need of the equipment, has moved into a Skilled Nursing Facility or has passed away. After Medicare pays for the 13 months rental, the equipment will become the beneficiaries. If repairs or maintenance is required on patient owned equipment, Medicare may pay for the repairs. Because the equipment is a rental for the initial 13 months, Sherman Oaks Medical Supplies can only rent within our service area and cannot bill Medicare for manual wheelchairs or transport wheelchairs purchased online.

If you live within our rental area please read below for manual wheelchair coverage.

A manual wheelchair is covered if:

Criteria A, B, C, D, and E are met; and Criterion F or G is met. Additional coverage criteria for specific devices are listed below.

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

A mobility limitation is one that:

Prevents the patient from accomplishing an MRADL entirely, or places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or Prevents the patient from completing an MRADL within a reasonable time frame.

B) The patient’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.

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

D) Use of a manual wheelchair will significantly improve the patient’s ability to participate in MRADLs and the patient will use it on a regular basis in the home.

E) The patient has not expressed an unwillingness to use the manual wheelchair that is provided in the home.

F) 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.

G) The patient has a caregiver who is available, willing, and able to provide assistance with the wheelchair. If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not medically necessary. If the manual wheelchair will only be used outside the home, it will be denied as not medically necessary. A standard hemi-wheelchair (K0002) is covered when the patient requires a lower seat height (17" to 18") because of short stature or to enable the patient to place his/her feet on the ground for propulsion.

A lightweight wheelchair (K0003) is covered when a patient:

The patient self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard wheelchair. The patient requires a seat width, depth, or height that cannot be accommodated in a standard, and spends at least two hours per day in the wheelchair. A high strength lightweight wheelchair is rarely medically necessary if the expected duration of need is less than three months (e.g., post-operative recovery).

A heavy duty wheelchair (K0006) is covered if the patient weighs more than 250 pounds or the patient has severe spasticity.

An extra heavy duty wheelchair (K0007) is covered if the patient weighs more than 300 pounds.

Coverage of an ultra-lightweight wheelchair (K0005) and manual tilt in space wheelchair (E1161) are determined on an individual consideration basis. Ultra-lightweight wheelchairs and tilt in space wheelchairs are paid for as a purchase because they must be custom ordered based on patient’s specifications and needs - pending Advance Determination of Medical Coverage. Patient’s medical records can be submitted to Medicare to determine coverage. This can take up to 30 days after the necessary documentation has been provided by the physician and other clinicians. Please contact Sherman Oaks Medical Supplies for more detailed coverage determination.

Sport wheelchairs and bathroom wheelchairs are not covered by Medicare.

4. Seat and Back Cushions for Wheelchairs

A general use seat cushion and a general use wheelchair back cushion are covered for a patient who has a manual wheelchair or a power wheelchair with a sling/solid seat/back which meets Medicare coverage criteria. If the patient does not have a covered wheelchair, then the cushion will be denied as not medically necessary. If the patient has a scooter or a power wheelchair with a captain's chair seat, it will be denied as not medically necessary.

A skin protection seat cushion is covered for a patient who meets both of the following criteria:

1) The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and

2) The patient has either of the following: a) Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface; or b) Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia (344.00-344.1), other spinal cord disease (336.0-336.3), multiple sclerosis (340), other demyelinating disease (341.0-341.9), cerebral palsy (343.0-343.9), anterior horn cell diseases including amyotrophic lateral sclerosis (335.0-335.21, 335.23-335.9), post polio paralysis (138), traumatic brain injury resulting in quadriplegia (344.09), spina bifida (741.00-741.93), childhood cerebral degeneration (330.0-330.9), Alzheimer’s disease (331.0), Parkinson’s disease (332.0).

A positioning seat cushion and positioning back cushion is covered for a patient who meets both of the following criteria:

1) The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and

2) The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (344.30-344.32, 438.40-438.42) or hemiplegia (342.00-342.92, 438.20-438.22) due to stroke, traumatic brain injury, or other etiology, muscular dystrophy (359.0, 359.1), torsion dystonias (333.4, 333.6, 333.71), spinocerebellar disease (334.0-334.9).

A headrest is also covered when the patient has a covered manual tilt-in-space wheelchair, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system.

If the patient has a mobility scooter or a power wheelchair with a captain's chair seat, a headrest or other positioning accessory will be denied as not medically necessary.

A combination skin protection and positioning seat cushion is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

A seat or back cushion that is provided for use with a transport wheelchair (E1037, E1038) will be denied as not medically necessary.

The effectiveness of a powered seat cushion (E2610) has not been established. Claims for a powered seat cushion will be denied as not medically necessary.