Frequently Asked Questions

Who Uses DME?

Many people use durable medical equipment (DME). In fact, in a 2001 survey, over 15 million Americans with disabilities reported using DME (National Institute on Disability and Rehabilitation Research, 2001). In a survey conducted by the American Association of Retired Persons (AARP, 2003), one-third of persons surveyed who were 50 years of age and older reported using some type of equipment or assistive technology. Almost one-quarter of persons 50 and older who are disabled but who do not use any specific equipment said that items such as a hearing aid, wheelchair, cane, or walker would improve their lives (AARP, 2003).

The process of getting the right kind of DME to suit your needs can be confusing, frustrating and difficult. Not having the right DME can limit your ability to live and work independently and can lead to preventable conditions such as pressure sores, infections and falls. If you understand what is involved, the process of getting your gear will make more sense. What Is Durable Medical Equipment (DME)?

Durable medical equipment (DME), according to the Centers for Medicare and Medicaid Services (CMS), is a health care device that helps a person with a mobility limitation to conduct activities in their home and community. This includes such items as wheelchairs, walkers, oxygen tanks, communication devices and hospital beds. The Centers for Medicare and Medicaid Services (CMS) defines durable medical equipment (DME) as any equipment that:

• Can withstand repeated use
• Is primarily and customarily used to serve a medical purpose
• Is not useful to a person who does not have an illness or injury
• Is appropriate for use in the patient's home

Who Can Get DME?

People who are admitted to hospitals and skilled nursing facilities for surgeries, illnesses or injuries will get the equipment they need before being discharged. In these situations, the equipment that people receive depends on why they were in the hospital. For example, if you go to a hospital for a hip replacement, the hospital will probably send you home with a walker and a raised toilet seat.

The process for getting DME without being in the hospital is different. You can pay for any piece of durable medical equipment yourself. However, because it can be expensive, people usually use their health insurance to pay for DME. Insurance carriers have different guidelines for what equipment they will pay for. For example:

Medicare pays for DME when you:

• have Medicare part B;
• have a doctor prescribe a covered item of DME; and
• need the device in order to function in your home.

(The Centers for Medicare and Medicaid Services, 2005)

Medicare will pay for a person's DME when "...beneficiaries who experience functional limitation of mobility are functionally hindered in their ability to perform mobility related aspects of daily living, such as toileting, feeding, dressing, grooming and bathing." (Claypool, 2005)

For example, if you cannot participate in any daily activities where you need to stand for a long time, if you cannot walk to the bathroom or to the kitchen, or if you are unsteady, you may be eligible to have your insurance carrier pay for your DME.

When you request that your insurance carrier pay for your DME, there are specific things that they will want to know. Your insurance company will be looking at your physical, cognitive and emotional limitations and abilities, your willingness to use the DME on a regular basis, and whether you could use this device safely in your home. You must send this information to your insurance carrier, which will decide whether or not it will pay for the equipment.

The evaluator will consider the following issues:

• Physical Limitations:
• Do you have weakness?
• Do you get tired easily, have decreased range of motion, coordination or sensation?
• Do you have a condition that prevents you from doing everyday tasks in your home without a mobility device?
• Mental Capacity:
• Can you understand how to use a mobility device safely?
• Physical Capabilities:
• Are your strength, speed, endurance, range of motion, coordination, and sensation sufficient for you to use a mobility device safely?
• Home Environment:
• Are there obstacles like furniture that would make it hard for you to use a wheelchair in your home?
• Are there stairs that would be a barrier to wheelchair use?
• Is the distance too far to walk with a walker, or too short for you to need a wheelchair?
• Willingness:
• Would you use the device regularly, or would it sit in a corner of your home or workplace?

(The Centers for Medicare and Medicaid Services, 2005;
Medicare Payment Advisory Commission, 2004)

How Do You Get The DME You Need?

Once you decide that DME is the right choice for you, there are several steps involved in getting it. If you are able to pay for the equipment yourself, you can go to any DME vendor in your area that has the equipment you would like and you can purchase it. Depending on whether it's in stock and available, you may be able to pick up the DME immediately or usually within several weeks.

However, DME is often very expensive and many people cannot afford to purchase DME on their own. Most people need to use their health insurance for financial assistance. In order for your insurance company to pay, there are specific procedures that must be followed. These steps are shown in Figure 1 and explained below.

Steps To Get Your DME

1. Talk to your doctor

Getting DME begins with talking to your doctor about your need for equipment. Some questions to ask yourself and to discuss with your doctor, depending on your situation and needs, are:

1. Are you able to get around in your community and into the places you need to go (work, supermarket, library, doctor's office, etc.)?
2. Do you feel safe while you are doing everyday activities or would you feel safer with something to support you?
3. Do you fall? How often? What time of day? During what specific activities?
4. Do you know of a piece of equipment that might work well for you?
5. Could you support yourself on a walker, or are your arms too weak or do you have too much pain?
6. Do you need a wheelchair or scooter in your house to get around?
7. Does the wheelchair you have fit in your house?
8. How far can you push your manual wheelchair without getting tired?
9. Are your arms too weak to push a manual wheelchair?
10. Is your wheelchair too heavy to lift into your car? If you had a lighter wheelchair, could you lift it independently?

2. Decide what kind of DME may be best for you

Your diagnosis or disability is not clear enough for doctors and suppliers to determine what mobility device or other DME would be best for you. What is best for one person may not be good for someone else. It is important to determine which piece of equipment would be best for you based upon how it would improve your ability to participate in daily activities. Take, for example, two people who each have Multiple Sclerosis. One person may need a power wheelchair to get from one place to another. The other person may need a cane for support. Both have the same diagnosis; however, their needs for DME are very different.

Research the available equipment options and discuss your needs with your doctor. Together you can come up with the best option for you. Along with speaking with your doctor, the process of obtaining DME includes an evaluation done by a physical therapist, occupational therapist or another health care professional often in conjunction with a supplier who will know more about the different types of equipment.

The best piece of equipment for an individual is often the device that can offer the least amount of support with the greatest amount of success. For example, if you can get to the bathroom and stand and brush your teeth with a cane for support, then a power wheelchair would get in the way. However, if you are able to walk with a cane, but then get too tired from walking to brush your teeth once you get to the bathroom, then a wheelchair may be a better choice.

If you are unfamiliar with DME and how it works, you should consider:

• Visiting DME vendors. They will have samples and know of stores where you can look at some options (see information below on how to find a DME vendor in your area).
• Speaking to other DME users. Talk with friends and others to find out their experiences and recommendations.
• Using the Internet to learn more about DME that may be right for you.

There are three aspects to consider when deciding what equipment might be best for you:

• Your functional limitations and abilities;
• Your home environment; and
• Your safety.

It is important to discuss these areas with your doctor and the DME evaluator. (See also step 5, below.)

3. Your doctor will write a prescription for DME

Have your doctor write a prescription for the type of DME that the two of you decide is best. Your doctor may give you additional forms that you will need to give to the DME vendor. If your doctor does not have these forms, they will be available through the DME vendor. The doctor who provides the DME prescription will also have to sign these forms.

4. Take the prescription to a certified DME vendor
What is a DME vendor?

A DME vendor is a company that specializes in DME. DME vendors have staff who are experts in equipment. Some are physical therapists (PT), occupational therapists (OT) and certified rehabilitation technology suppliers (CRTS). The vendors work with the companies that make the equipment as well as your insurance carrier. How do you find a DME vendor?

Your health insurance carrier may allow you to choose your own DME vendor. However, your insurance company may have a recommended DME vendor, and they may only pay for equipment you get through this vendor. Many times the DME vendor who has the contract for your insurance may not be the best qualified to handle your needs. Ask your insurance carrier what you may do if you are not satisfied with their vendor. You are the consumer!

If you have a choice of vendor:

1. Your doctor can recommend a DME vendor.
2. Ask your friends if they can recommend a DME vendor in your area.
3. Telephone your local drug store, pharmacy or medical supply company and ask if they know of DME vendors in your area.
4. Look in the yellow pages under hospital equipment and supplies, surgical appliances and surgical supplies.
5. Look on the internet for DME. You can type "durable medical equipment" into any search engine such as "Google".

Before you choose a DME vendor, ask questions, such as:

1. What equipment is available that fits your needs?
   * Do they carry the brand of product you prefer?
2. What equipment will your insurance carrier pay for?
   * Will your insurance cover part, or all, of the cost of the equipment?
   * How much expense will be out of pocket for you? (Sometimes it is worth paying for what your insurance will not cover to get what you need. For example, if you really want a certain kind of seating but are only eligible for standard seating, it may be worth paying the extra cost to get what you need and want.)
3. How long the vendor has been in business? How many requests have they filed with your insurance carrier? (The more experienced the vendor, the greater the chances of the process going smoothly.)
4. How many approvals and denials have they had for the specific DME you want? (Knowing this information may help you find a vendor who understands the process.)
5. Once your equipment is ready, will you need to pick it up or will they deliver?
6. Who does repairs? Will they pick up your DME and return it to you once it is repaired? How long do repairs usually take? Will the vendor provide loaner equipment to use while yours is being repaired? (National Seating and Mobility, 2005; Xtreme Medical, 2005)
7. Does the vendor offer a comprehensive array of equipment? You need to know as much as possible about the different types of equipment to match your unique needs.

5. Schedule an evaluation with the vendors' evaluators (PT, OT, CRTS)

Once you find a vendor and they receive the doctor's prescription, the vendor will set up an evaluation with a physical therapist (PT), occupational therapist (OT) or certified rehabilitation technology supplier (CRTS). The evaluator will make an appointment with you for a home evaluation. Some evaluators ask you to come to their office and have you describe your home environment.

If you need equipment for other community activities, such as working or attending school, be sure to ask if they can evaluate you in those environments as well.

The evaluation forms have areas to explain why you need the equipment and any accessories, such as a specific type of seat, brake or foot plate. Even if you think the evaluator already knows, explain to them why you need each item of equipment. Be sure the evaluators write down your explanations on the form.

Remember, the three aspects you will need to cover are:

1. Your functional limitations/abilities
2. Your home environment
3. Your safety

(The Centers for Medicare and Medicaid Services, 2005;
PacifiCare, 2005; Blue Cross Blue Shield, 2005)

A. Your functional limitations and abilities

You will need to explain your abilities to the evaluator. Questions that should be asked by evaluators to determine the best piece of equipment for you include:

1. Do you have a mobility limitation that limits your ability to perform one or more mobility-related activities of daily living at home, such as cooking, cleaning, getting dressed?
2. Do you have other conditions, such as fatigue or pain, that limit your ability to perform mobility-related activities of daily living at home?
3. If you have other limitations, will a mobility device improve your ability to perform mobility-related activities of daily living at home? How?
4. Are you willing and able to use a mobility device?
5. Can your mobility limitation be supported by a cane or walker, or will you need more support?
6. Do you have enough upper extremity function to propel a manual wheelchair at home during a typical day?
7. If a manual wheelchair is not enough support, do you have enough strength and postural stability to operate a scooter or power chair (including headrests and controls)? For example, can you use a joystick hand control or will you need to use your mouth to drive?
8. Will you need additional features provided by a power wheelchair in order to be able to perform one or more mobility related activities of daily living? (Power chairs and scooters are often more expensive than manual chairs. It is important to explain in detail why one gives you a greater functional improvement over the other.)
9. Do you need a certain seating option, wheelbase, or device weight? Why?
10. Do your usual environments support the use of a wheelchair or scooter or power wheelchair? For example, could you get into and around your home or workplace in a wheelchair?

B. Home environment

When filling out the DME request, it is important to think about your personal experiences within each of your usual environments. Your home environment is the one your insurance carrier will look at first to determine if they will help pay for DME. Items they will want to know are:

1. What does your home look like?
2. Are there walls or counters that you could use as support when you are walking through a room?
3. Do you need to use the counters or walls to support yourself so you don't fall?
4. Do you have a lot of furniture or items that would get in the way of a mobility device?
5. Are there stairs or steep ramps or slopes that would be hard to get a wheelchair up?
6. Are your door frames too narrow to get through with a walker or wheelchair?
7. Is your bathroom too small to use with a wheelchair?

All of these items can affect whether or not your insurance carrier will consider you to be eligible for specific equipment. If you cannot use the item in your home, chances are your request for the piece of equipment will not be approved.

C. Safety

Being safe will help to prevent injury and other problems. When a DME evaluator conducts a home evaluation or interview, they will want to know which activities that you do may be unsafe and why and how the DME you are requesting might help you to be safer. Your abilities and limitations, fatigue, and obstacles in your home environment can all be reasons that an activity is unsafe. If you are unsafe or falling frequently, DME might help.

6. Complete DME request forms

Know what your insurance company will cover. This information can be found in your member information under an "explanation of benefits" section. If your insurance company does not consider an item to be DME, then your request will be denied. Your DME request may be approved by your insurance carrier if it is a piece of equipment that is already considered "approved DME," and if your functional limitations and home environment meet the criteria set by your health care coverage.

Your health insurance will require the DME evaluator, your doctor and you to complete and sign a form, sometimes known as a "DME Form for Medical Necessity." You can get this form from the DME vendor or your doctor.

On the form, the evaluator will write an explanation of what you need and exactly why you need it. For example, the evaluator might say, "Jane Doe needs a lightweight wheelchair (model number, name, etc.) because it is 4 lbs lighter than the average model and will prevent further deterioration of her shoulders and prevent her from needing a power wheelchair."

If you are requesting replacement DME:

To avoid denial or delay, your DME request must include information regarding the condition of your existing equipment and why you need a replacement instead of having your existing equipment repaired.

7. Submit DME request to health insurance company

All of the DME request forms must be signed by the same doctor who wrote the original prescription for DME. Once signed, the DME vendor will send the forms and prescription to your health insurance company for approval. You should follow up with your vendor to see that the request has been filed. Be sure to keep a copy of everything submitted for your own records, and in case your paperwork gets lost in the process.

8. Wait for a response from your health insurance company

The approval process takes about two to three weeks with private insurance, six to eight weeks with Medicare, Medicaid/Medi-Cal. Be sure to get your claim number from the DME vendor and the address or phone number for your insurance carrier so you can follow up to check on the status of your request.

If your request is denied, you need to find out why and then resubmit; see What Are Common Reasons for DME Denial, below.

9. Approved!

Your insurance carrier will notify you in writing of their decision. If you receive a letter of approval, contact your DME vendor. The DME vendor may contact you if they receive the approval letter, or the DME vendor may request a copy of the approval letter from you. Be sure to keep a copy of the letter for your records.

10. Schedule an appointment for final DME fitting

Once you receive an approval letter and your vendor tells you that your DME is ready, make an appointment for a final fitting and adjustments. For example, if you ordered a specific seating system, your vendor may need to adjust it to be sure it fits your body properly. Adjustments may also be needed for your headrest, foot rests, back rest and tires.

If your equipment is in stock, it may take one to two weeks to get the appointment, depending on availability of appointment times. If your equipment cannot be ordered until approval is received, it could take two to six weeks to get an appointment, depending on the availability of your equipment.

At your appointment, most adjustments can be made on the spot and you may be able to leave with your equipment. However, if more complex adjustments need to be made or an accessory does not fit, it may take an extra two to three weeks before you are able to take your equipment home.

11. Schedule an appointment for pick up or delivery

After your final adjustments are made and your equipment is ready, you will be able to pick up your equipment or have it delivered. Check with the vendor regarding how pick up or delivery is handled. You may be able to pick up the equipment on the same day that you have your final fitting. You may also be able to have final adjustments made in your home when your equipment is delivered.

What Are Common Reasons For DME Denial?

If your request for DME is denied:

1. Determine the reason for the denial. You should receive a letter that states why your request was denied. In some instances, the reason is given as a number and sometimes as a short statement. If it is confusing, you can ask your doctor or DME vendor to clarify. If it is still unclear, you or your DME vendor can follow up with your insurance carrier to request a more complete explanation.
2. Once the reason for the denial is established, you, your doctor, and the DME evaluator can work together to make the necessary changes or add additional information to your request so it can be resubmitted. You should expect the resubmission process will take just as much time as the first round of application.

Common reasons for denial:

1. Inadequate justification for particular equipment
   This could mean that you, your doctor or evaluator did not describe in enough detail why you need this piece of equipment. You may need to provide more detail as to how this DME would help you to be safer, would help prevent further injury or health conditions, or how another kind of equipment is not right because of limitations that you have. If it is a replacement piece of equipment, the insurance company may deny replacement. They will want to know the current condition of the previous piece of equipment and why it needs to be replaced instead of repaired.
2. Not approved DME
   Your insurance provider has a list of DME that they will approve. If the DME you are requesting is not on that list, it is not likely to be approved. It is important to know what your carrier usually covers. For Medicaid/ Medicare, you can find this information on www.medicare.gov or you can ask the vendor for a list. For other insurance companies, you can call and ask the company directly. A list of approved DME may have been included in your initial enrollment package or your carrier's "explanation of benefits" information.
3. Only partial coverage available
   You may be denied partial coverage because your insurance carrier may only cover part of the equipment you need. For example, your carrier may only approve the cost of one hearing aid, even though you may need two. This information is usually included in the "explanation of benefits" document available through your insurance company.
4. There were different doctor's names on the forms
   The signature on the form is not the same as the signature on the prescription. This can occur when someone has to change doctors in the middle of the process. If you do change doctors, it is important to get another prescription from the new doctor, the same one who will be signing the DME request form.
5. Too early for renewal of prescription for particular equipment
   If you are requesting a replacement for worn or broken equipment you already have, your insurance limits how often you can submit requests for DME. It is important to be aware of these timelines. Typically the replacement interval is every five years, but this may vary. Consult your insurance carrier's "explanation of benefits" document to determine the timelines. It is important to start the process of requesting DME early because it does take a while.
6. Inadequate description of deterioration of function/ or prevention of further injury
   If you are submitting a request for a new piece of equipment because your condition or limitations have changed, it is important to provide as many details as possible. If you have in the past only needed a cane, but now feel you need a walker to get around, it is important to describe the change in your physical condition in detail.
7. Equipment does not serve a "medical purpose"
   Some insurance carriers do not consider items that are usually considered for hygiene or personal use as "medical" including such devices as bathtub seats, lifts, or exercise equipment and will not cover them as DME. Some carriers will cover bathroom equipment, it is important to check what your insurance carrier considers DME before placing an order.
8. The item being requested is considered an "item of personal convenience" or "not reusable," therefore not DME
   Again, you can obtain this information from your insurance carrier before requesting DME. They can provide you with a list of what they consider to be "items of personal convenience." Often these are items such as surgical gloves, irrigating kits or grab bars. Some private insurance companies will pay for these items as "supplies" if they are not considered DME.

(The Centers for Medicare and Medicaid Services, 2005; PacifiCare, 2005; Blue Cross Blue Shield, 2005; National Seating and Mobility, 2005; Xtreme Medical, 2005)

Who Follows Up On Your Order?

You do. To make sure everything has been filed and the process is going smoothly, you should follow up with your DME vendor. Remember, they handle hundreds of requests so you also will want to follow up with Medicare, Medicaid or your private insurance company directly to check on the status of your claim.

You should keep a copy of every form filed with your request and get any claim numbers and all contact information. Make sure your doctor knows also how long the process is taking and what is happening so that he/she will be able to assist you in following up when necessary.

Conclusion

Getting the right gear for your unique needs can be a challenging and time consuming process. Using the information provided here and attending to the details can help make the process go a little more smoothly and reduce the chance of having your request denied. It is important that you take charge of getting your DME. It is your responsibility to make sure you get the right gear.

References

• The Access Center of San Diego/ Spoke Shop (2005). Telephone Interview with evaluator. www.a2isd.org/
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• Blue Cross Blue Shield, (2005). Downloaded from www.bcbs.com
• Carlson, D., Ehrlich, N., Berland, B.J., and Bailey, N. (2001). Assistive Technology Survey Results: Continued Benefits and Needs Reported by Americans with Disabilities. Washington, DC: National Institute on Disability and Rehabilitation Research
• The Centers for Medicare and Medicaid Services (2004). Press Release: Medicare opens National Coverage Determination to Make Sure Beneficiaries Who Need Wheelchairs Get Them. Downloaded from www.cms.hhs.gov The Centers for Medicare and Medicaid Services (2005).
• Medicare.org; A Resource for Medicare Information. Downloaded from www.medicare.org, www.cms.hhs.gov Claypool, H, (2005)
• Navigating Medicare and Medicaid. Menlo Park, CA: Kaiser Family Foundation. Connecticut Department of Social Services (2001).
• How to Get Durable Medical Equipment through the Medicaid Program. Downloaded from www.dss.state.ct.us/svcs/medical/dme_broc.htm Independence through Enhancement of Medicare and Medicaid (ITEM) Coalition (2005).
• XXX. Downloaded from www.itemcoalition.org McNeil, John M (2001).
• Americans with Disabilities: Household Economic Studies. U.S. Bureau of the Census, Current Population Reports. Washington, DC: U.S. Government Printing Office Medicare Payment Advisory Commission (2004).
• Durable Medical Equipment Payment System. www.medpac.gov National Center for Health Statistics, (1994-1995).
• National Health Interview Survey on Disability, Phase I file. Hyattsville, MD National Seating and Mobility (2005).
• Downloaded from www.nsm-seating.com PacifiCare (2005).
• Downloaded from www.pacificare.com Spin Life (2005).
• Downloaded from www.spinlife.com Xtreme Medical (2005).
• Downloaded from www.xtrememedical.com

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Schwier, E., Kailes, J. (2006) Getting the Right Gear: Taking Charge of Obtaining Durable Medical Equipment. Published and distributed by the Center for Disability Issues and the Health Profession, Western University of Health Sciences, 309 E. Second Street, Pomona, CA 91766 1854, Voice: 909.469.5213; TTY: 909.469.5520; Fax: 909.469.5503; Internet: www.cdihp.org/products; Email: ahcs@westernu.edu

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