Durable medical equipment — commonly called DME — refers to medical equipment that is prescribed by a physician for use in the home to treat a medical condition or illness. It is designed to withstand repeated use, serve a medical purpose, and be appropriate for use in the home rather than only in a medical facility. Medicare, Medicaid, and most private insurance plans cover durable medical equipment when it is medically necessary and properly prescribed.
Understanding what qualifies as durable medical equipment, what is covered by Medicare, and how to obtain it can help patients and families access the equipment they need at the lowest possible cost.
What qualifies as durable medical equipment
To qualify as durable medical equipment an item must meet all of the following criteria:
- It must be durable — able to withstand repeated use
- It must serve a medical purpose
- It must be appropriate for use in the home
- It must be primarily used to serve a medical purpose rather than for comfort or convenience
- It must be prescribed by a physician
Items that are primarily for comfort or convenience — such as air conditioners, humidifiers used for general comfort, or exercise equipment — generally do not qualify as durable medical equipment even if a physician recommends them.
Common types of durable medical equipment
Durable medical equipment covers a wide range of items used in the home to support medical care including:
- Mobility aids — wheelchairs both manual and power, walkers, canes, crutches, and scooters
- Respiratory equipment — oxygen equipment and supplies, CPAP and BiPAP machines for sleep apnea, nebulizers for respiratory conditions
- Hospital beds — adjustable hospital beds and related accessories for use in the home
- Lift equipment — patient lifts, stair lifts, and seat lift chairs in some cases
- Diabetes supplies — blood glucose monitors, test strips, and insulin pumps
- Prosthetics and orthotics — artificial limbs, braces, and supportive devices
- Urological supplies — catheters and related supplies
- Wound care supplies — surgical dressings and wound care equipment in some cases
- Communication devices — speech generating devices for people who cannot speak
How Medicare covers durable medical equipment
Medicare Part B covers durable medical equipment that is medically necessary and prescribed by a Medicare-enrolled physician. To receive Medicare coverage for DME:
- Your doctor must prescribe the equipment and document that it is medically necessary
- The equipment must be obtained from a Medicare-enrolled DME supplier
- The equipment must be on Medicare’s list of covered items
Medicare Part B generally pays 80 percent of the Medicare-approved amount for covered DME after the annual Part B deductible is met. You are responsible for the remaining 20 percent coinsurance unless you have a Medigap policy or other supplemental coverage that covers this cost.
Medicare DME coverage categories
Medicare covers DME in several categories:
- Capped rental items — some items such as oxygen equipment and certain other equipment are rented rather than purchased. Medicare pays the rental cost up to a cap after which ownership typically transfers to the beneficiary.
- Inexpensive or routinely purchased items — items that cost relatively little or are typically purchased rather than rented such as canes and crutches
- Complex rehabilitative equipment — highly customized equipment such as power wheelchairs that requires special evaluation and fitting
- Prosthetics and orthotics — covered under Part B with specific coverage rules
Prior authorization for certain DME
Medicare requires prior authorization — advance approval — for certain types of durable medical equipment before coverage will be provided. Items that commonly require prior authorization include power wheelchairs and scooters. Prior authorization helps ensure that coverage is only provided for items that are medically necessary and meet Medicare’s coverage criteria.
Finding a Medicare-enrolled DME supplier
To receive Medicare coverage for durable medical equipment you must obtain it from a Medicare-enrolled supplier. Medicare has a competitive bidding program in many areas that requires you to use contract suppliers for certain types of equipment to receive Medicare coverage at the lowest cost.
Medicare’s Supplier Directory at medicare.gov allows you to search for Medicare-enrolled DME suppliers in your area. You can also call 1-800-MEDICARE for assistance finding a supplier.
How Medicaid covers durable medical equipment
Medicaid also covers durable medical equipment for eligible beneficiaries though the specific items covered and the coverage rules vary by state. Medicaid coverage for DME is generally available when the equipment is medically necessary and prescribed by a physician. Contact your state’s Medicaid agency for information about DME coverage in your state.
Veterans benefits and durable medical equipment
Eligible veterans may be able to obtain durable medical equipment through the VA healthcare system. The VA provides a wide range of DME to eligible veterans including mobility aids, respiratory equipment, prosthetics, and other items. Veterans who are enrolled in VA healthcare can obtain DME through VA medical centers and community-based outpatient clinics.
Tips for obtaining durable medical equipment
- Always get a written prescription from your doctor that clearly documents your medical need for the equipment
- Verify that the supplier is enrolled in Medicare before obtaining equipment if you want Medicare to cover the cost
- Ask your doctor or a social worker for help identifying the right type of equipment for your needs
- Compare prices from multiple suppliers especially for items not covered by insurance
- Ask about rental options before purchasing expensive equipment that you may only need temporarily
- Keep all paperwork including prescriptions, receipts, and insurance correspondence related to your DME
Appealing a Medicare DME denial
If Medicare denies coverage for durable medical equipment you have the right to appeal the decision. The denial notice will include information about how to request a review. Working with your physician to ensure that the medical necessity documentation is complete and thorough is one of the most effective ways to support an appeal.
Key terms to know
- Durable medical equipment — DME — medical equipment prescribed for home use that is durable, serves a medical purpose, and is appropriate for home use
- Medicare Part B — the component of Medicare that covers outpatient services including durable medical equipment
- Prior authorization — advance approval required by Medicare for certain types of DME before coverage is provided
- Competitive bidding — a Medicare program that requires beneficiaries in certain areas to use contract suppliers for specific DME items
- Capped rental — a Medicare payment method for certain DME items that are rented up to a cap after which ownership transfers to the beneficiary
- Prosthetics and orthotics — artificial limbs, braces, and supportive devices covered under Medicare Part B
- Medically necessary — a standard used by Medicare and other insurers to determine whether a service or item is covered
Sources
- Medicare.gov — Durable Medical Equipment
- Centers for Medicare and Medicaid Services
- U.S. Department of Veterans Affairs — va.gov
- USA.gov — Medicare
This article is for general informational purposes only and does not constitute legal or medical advice. Medicare and Medicaid coverage rules are subject to change. Consult a licensed healthcare provider or contact Medicare directly for guidance specific to your situation.