What DME is Not Covered by Medicare?

While Medicare Part B plays a crucial role in covering durable medical equipment (DME) for beneficiaries, it does not cover all equipment. Medicare primarily covers DME that is medically necessary, prescribed by a doctor, and used in your home.

It's important to understand that many items often inquired about for coverage, such as wheelchairs, walkers, hospital beds, power scooters, portable oxygen equipment, orthotics, prosthetics, and certain diabetes supplies, are typically covered by Medicare Part B when they meet specific medical necessity criteria and other requirements. However, numerous other types of equipment fall outside Medicare's coverage.

Categories of DME Not Covered by Medicare

Medicare sets specific criteria for DME coverage, leading to the exclusion of many items. Understanding these categories can help clarify what is generally not covered.

1. Items for Convenience or Comfort

Medicare generally does not cover items solely for convenience, comfort, or hygiene purposes, even if they might indirectly assist a person with a medical condition.

• Examples:
  • Grab bars
  • Raised toilet seats
  • Bathtub seats
  • Stairlifts
  • Air conditioners or humidifiers (unless part of specific, covered respiratory equipment)
  • Exercise equipment
  • Electric scooters (not designed as power-operated vehicles, often for recreational use)
  • Health club memberships or devices for general wellness

2. Home Modifications

Equipment that involves permanent alterations to your home or items considered home modifications are typically not covered as DME.

• Examples:
  • Ramps (permanent structures)
  • Widening doorways
  • Installation of lifts or elevators within the home

3. Items Not Primarily Medical in Nature

For an item to be covered as DME, its primary purpose must be medical. If an item serves a dual purpose but is not primarily medical, it may be excluded.

• Examples:
  • Heating pads for general comfort (as opposed to specialized therapeutic heating devices)
  • Air purifiers

4. Disposable Medical Supplies (Unless Tied to Covered DME)

While some supplies directly related to the effective operation of covered DME (e.g., oxygen tubing for a portable oxygen concentrator) are covered, many disposable items are not.

• Examples:
  • Adult diapers or incontinence pads
  • Basic bandages and wound dressings (unless part of specific wound care plans covered under other benefits)
  • Over-the-counter medications and supplies

5. Items Not Meeting DME Criteria

To be considered DME, an item must meet all of the following requirements:

• Durable: Able to withstand repeated use.
• Medical Purpose: Used for a medical reason.
• Home Use: Appropriate for use in the home.
• Long-lasting: Expected to last at least three years.
• Non-Personal Use: Not generally useful to someone who isn't sick or injured.

If an item fails to meet any of these criteria, it will not be covered as DME.

6. Equipment Not Prescribed or Medically Necessary

Even if an item falls into a generally covered category, it won't be covered if it's not prescribed by a doctor or if Medicare deems it not medically necessary for your condition. This includes experimental equipment or items used for non-FDA-approved purposes.

Summary of Exclusions

To help differentiate, the following table provides a quick overview of what is generally covered vs. generally not covered under Medicare Part B for DME.

Understanding these distinctions is essential for Medicare beneficiaries planning their healthcare expenses. Always consult with your doctor and Medicare directly for specific coverage questions related to your needs. Learn more about Medicare DME coverage.