Medicare (Part B) covers assistive technology devices which meet its definition of "durable medical equipment" or a prosthesis if

1) Provided by a supplier with a Medicare billing number

2) Either reasonable or necessary for the treatment of illness or injury or to improve the functioning of a malformed or malfunctioning body part or organ system.

Durable medical equipment (DME) means that the device can withstand repeated use; is primarily or customarily used to serve a medical purpose; generally is not useful to an individual in the absence of illness or injury; and is appropriate for use in the home. Home includes your own home or apartment, relative’s home and most institutional settings except a hospital and skilled nursing facility.

Prosthetic and orthotic devices are devices which:

Replace all or part of a body organ, leg arm, back and neck braces and artificial legs, arms and eyes.

Items are not covered if they are seen convenience items. The denial will state that the item is not used primarily to serve a medical purpose; can be used by someone who is not ill or injured; or cannot be used in the home.

• Get a Certificate of Medical Necessity (CMN) from your doctor. The CMN is the doctor’s prescription for the device. It must state the diagnosis, prognosis, the reason the device is required and an estimate of the length of time the device will be needed.

• Take the CMN to a supplier with a Medicare billing number.

• You purchase the equipment from the supplier and the supplier submits the claim and the CMN to Medicare for reimbursement.
• The claim will be reviewed by the DMERC who will send you an explanation of Medical benefits.

For claims that are accepted, you have to pay the yearly deductible of $100.00. Medicare pays 80% of the "approved amount" listed on the Explanation of Medical Benefits. If the supplier accepts "assignment" which is the Medicare approved amount as payment in full, you must only pay the remaining 20% of the Medicare approved amount. If the supplier does not accept assignment, you must pay the remaining 20% plus any amount charged by the supplier above the Medicare approved amount.

If Medicare does not pay, usually you are liable for payment unless the supplier knew or should have known that the claim would be denied and didn’t tell you. Before signing a waiver of liability that requires you to pay for an item, call the DMERC to ask if the supplier is in good standing and has a Medicare Billing number, and what part of the cost Medicare will cover.

Documentation showing medical necessity and usefulness of the item is especially necessary when dealing with special features of equipment and with appeals of denied claims. Customized and deluxe features are covered only if shown through documentation to be medically necessary for functioning in the home environment.

• If the claim was not filed correctly, ask the doctor or supplier to resubmit.
• If the claim was filed correctly, send a copy of the EOMB containing the denial back to Medicare within 6 months with a signed note asking for a review by the DMERC.
• If you lose the review, you have 6 months to request a fair hearing by the DMERC.
• If you lose the fair hearing, you can request within 60 days a hearing with an administrative law judge (ALJ). Some claims have been won at the ALJ level. It may take at least a year to reach the ALJ level. During this time you may have to pay the full cost of the item and wait more than a year for Medicare reimbursement.
• The final step is having the case heard in federal court.