what is durable medical equipment consist of

However, Medicare Part D does not cover insulin for diabetes when it is administered with an insulin pump. In that case, insulin for diabetes may be covered under Medicare Part B as durable medical equipment, as indicated above. Medicare Part D also covers other drugs that can help control diabetes.

Medicare Diabetes Coverage

Share Print Medicare Diabetes Coverage Diabetes is a common medical condition in which the body either doesn't make enough insulin or doesn't respond properly to the insulin it makes. A healthy body uses insulin to process sugars, but when there isn't enough insulin in the body, too much sugar stays in your blood. If your blood sugar remains consistently high, your doctor may diagnose you with diabetes. The information contained in this article is for informational purposes only.

It should never be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition. Medicare Part B and Medicare Part D generally cover the services and supplies needed to control diabetes. Here's a breakdown of how Medicare covers diabetes. How Medicare Part B covers diabetes Medicare Part B covers the fasting blood glucose test, which is a diabetes screening. Medicare covers two diabetes screenings each year for beneficiaries who are at high risk for diabetes.

High risk factors for diabetes include: high blood pressure, history of abnormal cholesterol and triglyceride levels, obesity, or a history of high blood sugar.

If diabetes runs in your family, you may also need regular diabetes testing. Your doctor may also recommend services that Medicare doesn't cover. You generally pay nothing for these diabetes tests if your doctor accepts the amount approved by Medicare for the diabetes screening.

However, you may have to pay 20% of the amount approved by Medicare for the doctor's visit. If your doctor diagnoses you with diabetes, Medicare covers the supplies you need to control your diabetes, including blood sugar testing monitors, blood sugar test strips, lancet devices and lancets, and blood sugar control solutions. Medicare Part B may cover an external insulin pump and insulin as durable medical equipment (DME). You pay 20% of the amount approved by Medicare, after the yearly Medicare Part B deductible. Diabetes may result in blood-circulation problems that can become serious over time.

For example, poor blood circulation increases the risk of problematic foot disease issues. Medicare Part B covers foot exams every six months, as long as you haven’t seen a foot care professional for another reason between visits.

Therapeutic shoes are also covered for people with diabetes who need special footwear. Medicare may also cover medical nutrition therapy for diabetes, if referred by a doctor.

You pay 20% of the amount approved by Medicare after the yearly Medicare deductible for services related to diabetes. If diagnosed with diabetes, Medicare Part B may cover up to 10 hours of initial diabetes self-management training. You may also qualify for Medicare coverage for up to two hours of follow-up diabetes training each year.

Training is only for those at risk or recently diagnosed with diabetes, and you must have a doctor's or health-care professional's written order for the diabetes training. How Medicare Part D covers diabetes Medicare Part D is Medicare prescription drug coverage, which is available through either a stand-alone Medicare prescription drug plan or a Medicare Advantage Prescription Drug plan. Because insulin is a prescription drug used to control diabetes, Medicare Part D covers insulin.

If you're diagnosed with diabetes, you will need certain medical supplies to administer the insulin. Supplies may include syringes, needles, alcohol swabs, gauze, and inhaled insulin devices. Medicare Part D covers these medical supplies for diabetes.

Under Medicare Part D, you may pay a coinsurance or copayment as well as a potential Medicare Part D deductible, depending on your Medicare prescription drug plan or Medicare Advantage Prescription Drug plan.

Part B also covers medically necessary durable medical equipment such as wheelchairs and walkers to treat a disease or condition. Costs for Part B services vary, but frequently, you will pay a deductible and then 20% of the Medicare-approved amount, as long as you use providers who accept Medicare assignment. Most people pay a premium for Part B.

What Is the Difference Between Medicare Part A and Part B?

What Is the Difference Between Medicare Part A and Part B?by Donald Kreis | Licensed since 2002Print This article was updated on: 11/17/2015Find Affordable Medicare Plans in Your Area Original Medicare is made up of two parts: Part A, hospital insurance, and Part B, medical insurance.

They can work together, but coverage does not overlap. Medicare Part A covers your hospital expenses. This includes hospital stays, skilled nursing care (as long as custodial care isn’t the only care you need), hospice, and home health-care services.

Part A services may require you to pay various deductibles, coinsurance, and copayments. Many people qualify for premium-free Part A because they or their spouse paid taxes toward Medicare while working for at least 10 years (or 40 quarters).

But otherwise, you may have to pay a monthly premium. Medicare Part B is your health insurance coverage. It covers two types of services, including medically necessary services to treat illnesses or conditions, such as doctor’s office visits, lab work, x-rays, and outpatient surgeries, and preventive services to keep you healthy, like cancer screenings and flu shots.

Even if you’re enrolled in a Medicare Advantage plan that provides your Part A and Part B benefits, you still have to pay your Part B premium.

Hopefully, this gives you some basic information about Part A and Part B of Original Medicare. Feel free to visit Medicare.gov for additional information on Part A and Part B coverage. Of course, I am happy to answer any other questions you might have. Check out my profile by clicking the “View profile” link below if you’d like to know more about my background.

We can go over Medicare plans that might work well for you; use the links below to schedule a phone call with me or have me email you plan options. If you’d like to compare plans on your own, we’ve made it easy for you to do that. Use the Compare Plans buttons on this page.

Ready to discuss your options? Call Medicare.com’s licensed insurance agents at 1-844-847-2659, TTY users 711; Monday through Friday, 8AM to 8PM ET.

Find Affordable Medicare Plans in Your Area Related Medicare Articles Medicare Eligibility If You Are Under 65Medicare Part A – Hospital Insurance Original Medicare vs. Medicare Advantage Pros and Cons of Delaying Medicare Part B Enrollment Getting Medicare When You’re Married Donald Kreis View profile Licensed Insurance Agent since 20021- 844-847-2659TTY users 711Mon - Fri, 8am - 8pm ETGet a Plan Recommendation Schedule a Phone Call Compare Plans Now

Our equipment at Genesis is second to none: We use the best durable medical equipment and orthopedic supplies that money can buy to service the patients that are prescribed to us.

We at Genesis Medical personally spend as much time as possible with each and every patient to insure the prescribing physician is getting what he or she wants accomplished.

All of our equipment is PDAC coded and approved by Medicare. We can get almost any make, model, or brand of equipment that the physician or medical staff wants.

*We do all pre-certifications for the doctor’s office. * We also fit patients at our comfortable office, at their home, or wherever the patient requests. Locally Owned and Operated We are a locally owned and operated D. M. E. company in Louisiana (not based in other states as most other D. M. E. companies are).

After every fitting we do a pain reduction and/or comfort report, to show the doctors and medical staff the outcomes on each and every prescription (if the patient allows). We love what we do and it shows.

The following NYS Medicaid durable medical equipment (DME) fee schedule columns will not be applicable in the WC DME fee schedule: MAX UNITS: Maximum units allowed per month. PA: Prior approval. CHANGE: The CHANGE column indicating a change in the code since the last fee schedule was posted.

Medical Care Fee Schedules

Medical Care Fee Schedules Medical Fee Schedules Workers' Compensation Enhanced Ambulatory Patient Group (EAPG) Ambulatory Surgery Fee Schedule Thank you for your feedback on the Medical Fee Schedule Discussion Document.

Your feedback is very valuable to the Board and will be given careful consideration in revising the proposed document.

Podiatry Fee Schedule Dental Fee Schedule Frequently Asked Questions about Dental Fee Schedule Errata 3/1/11Errata 10/26/13Pharmacy and Durable Medical Goods Fee Schedules and Appendices Frequently Asked Questions about Pharmacy Fee Schedule and Pharmacy Benefit Manager (PBM)Frequently Asked Questions about Durable Medical Equipment (DME) Fee Schedule Pharmacy Fee Search: July 11, 2007 through July 6, 2008 only Durable Medical Equipment Fee Schedule The Workers' Compensation Board has adopted the NYS Medicaid durable medical equipment (DME) fee schedule.

The most recent DME fee schedule is found in the Department of Health's e Med NY e Med NY web site. This e Med NY site also provides periodic provider communications, announcements, manuals and fee schedules - What's New.

Historic fee schedules and other information that is more than four months can be found in the Archives.

The NYS Medicaid durable medical equipment (DME) fee schedule will have these exceptions: According to Section 442.2 (a) of the WC DME Fee Schedule (12 NYCRR part 442): For orthopedic footwear (DME codes from L3000 to L3649) or if the New York State Medicaid program has not established a fee payable for the specific item (DME items with a blank reimbursement value in the fee schedule), then the fee payable, shall be the lesser of:the acquisition cost (i.e.

the line item cost from a manufacturer or wholesaler net of any rebates, discounts or other valuable considerations, mailing, shipping, handling, insurance costs or any sales tax) to the provider plus 50%; ORthe usual and customary price charged to the general public.

Note: The Medicaid provider manual for durable medical equipment and the policy guidance do not apply to workers' compensation except to the extent such documents contain the Medicaid durable medical equipment fee schedule.

Application of the durable medical fee schedule is based on Workers' Compensation statute, rules and regulations in addition to the durable medical equipment fee schedule.

Only the Board in the exercise of its adjudicatory function is authorized to determine entitlement to benefits based on the specific facts of a given claim and the application of the law to those facts. No-Fault cases may be subject to differing interpretations. For information regarding No-Fault Insurance, contact NYS Department of Financial Services at dfs.ny.gov. Notice of Decision dated April 21, 2009, concerning request for fee schedule adjustment: In the Matter of Request by EMPI, 2009 NY Wrk Comp.

DIVERSIFIED MEDICAL PRODUCTS, INC. Durable Medical Equipment & Medical Supplies A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient?s use in the home and that are usable for an extended period of time.

DIVERSIFIED MEDICAL PRODUCTS, INC.

Share Tweet Reviews Edit my contact information Contact Information DIVERSIFIED MEDICAL PRODUCTS, INC.2260 COUNTY ROAD 26MARENGO, OH 43334-9776 Phone: 419-253-0611 Fax: 419-253-0711 Website: Specialty Taxonomy Code Specialty Code Provider Type Durable Medical Equipment & Medical Supplies332B00000X54 Other Medical Supply Company Indicates primary specialty Edit contact information NPI Profile & details for DIVERSIFIED MEDICAL PRODUCTS, INC. NPI Number 1710919725LBN Legal business name DIVERSIFIED MEDICAL PRODUCTS, INC.

Authorized official RHONDA MAPLES - (PRESIDENT)Entity Organization Organization subpart 1 No Enumeration date 07/07/2006Last updated 03/13/2008 - About 10 years ago Identifiers OH Medicaid 0678735OH Other D22 MEDIGOLD1Some organization health care providers are made up of components that furnish different types of health care or have separate physical locations where health care is furnished. These components and physical locations are not themselves legal entities, but are part of the organization health care provider (which is a legal entity).

A covered organization provider may decide that its subparts (if it has any) should have their own NPI numbers. If a subpart conducts any HIPAA standard transactions on its own (e.g., separately from its parent), it must obtain its own NPI number.

Submit Review Reviews for DIVERSIFIED MEDICAL PRODUCTS, INC. There are currently no reviews for DIVERSIFIED MEDICAL PRODUCTS, INC. Be the first to post a comment or review .

Read our reviews / comments about this provider to help you decide if they are right for you. Share your experience by posting a comment or review about this provider to help others decide which is right for them.

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One mistake that some people make is purchasing items they believe they need and then filing a claim through Medicare for the durable medical equipment. This will not be approved in this manner. Rather, your doctor must specifically prescribe the equipment for you to use.

Can I Just Buy It?

Introduction Written by Nancy Mc Mahon Can I Just Buy It?

During this prescription process, they must note that the equipment is necessary for your health. They will need to complete a specific form from Medicare, called the Durable Medical Equipment Necessity Form. Many doctors will have these forms available to them, but they can also be obtained directly from your local Medicare office.

You will need to submit your claim along with this paperwork directly to Medicare. Your medical equipment supplier must also submit all paperwork for your claim directly to Medicare to be reimbursed. Medicare will pay the supplier of the equipment directly for your equipment. The amount that Medicare will pay is set. They determine what is considered the maximum rate for this equipment, then will pay 80 percent of that approved amount for you.

Payment to the suppliers is done in monthly payments, in most cases. Anything valued at $150 or less will be paid in full at the time of purchase.

Anything over that is paid in monthly payments, considered a rental payment, for the equipment. These monthly payments will continue throughout the time you need the equipment. Medicare will consider the item paid in full after a period of 15 months, if you continue to need and use the equipment for that length of time.

If you have problems with your equipment over the time that you own it, Medicare will pay for repairs to it, assuming they are considered necessary repairs to keep the item working in good condition.

service of equipment is not covered. Plus, if the cost of repair is more than the equipment is worth, Medicare will not pay for that additional cost.

While most decisions made by Medicare on what is and what is not covered are considered valid, you do have the right to file a claim that you do not believe the decisions were correct. The process may take some time, but there are several appeal processes to work through. You may want to consider legal help for this process, though it is not considered necessary.

You will have the right to show your case and be heard as to why you believe the costs should be covered. If you have a need for durable medical equipment, do not purchase it directly. Rather, talk to your doctor about your medical need and work through your doctor for approval of the item.

Suppliers of medical equipment may be able to help you find the right equipment that's covered (as much as possible) through Medicare. If you believe you may qualify for this coverage, talk to your local Medicare office before making a purchase. For those who are struggling to make payments on medical equipment, Medicare's plan may be helpful. If you have insurance through other means, though, you may not qualify for this plan. Talk to your insurance company directly to find out what type of coverage is available to you through them.

Many people find that the process of filing a claim for durable medical equipment is not as difficult as they believed. Most suppliers and doctors are well informed about the process and will help you through the process. You can also work directly with the local Medicare office for more information and guidance.< Prev Next > [ Back ]

ed? Medicare Part B (Medical Insurance) covers knee CPM machines as durable medical equipment (DME) that your doctor prescribes for use in your home,

Your Medicare Coverage

Is my test, item, or service covered? Go Continuous passive motion (CPM) machine How often is it cover

if you meet certain conditions. Who's eligible? All people with Part B are covered. Your costs in Original Medicare If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Medicare pays for different kinds of DME in different ways. Depending on the type of equipment: You may need to rent the equipment. You may need to buy the equipment. You may be able to choose whether to rent or buy the equipment.

Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare.

If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them. It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment. If suppliers don't accept assignment, there’s no limit on the amount they can charge you. Find a Medicare contract supplier.

Note To find out how much your test, item, or service will cost, talk to your doctor or health care provider.

The specific amount you’ll owe may depend on several things, like: Other insurance you may have How much your doctor charges Whether your doctor accepts assignment The type of facility Where you get your test, item, or service Related resources Where to get covered DME items More information about DMEReturn to search results

Medicare does not pay for extended care. Medicare also covers up to 100 days of nursing home care in limited instances, and it helps cover the cost of some durable medical equipment for home use. It also covers hospice care for people diagnosed with a terminal illness and a life expectancy of six months or less.

Planning and Funding Care

Planning and Funding Care The cost of long-term care for seniors varies as much as the types of care available and the degree of assistance you or a loved one need.

In this article, we review some of the more common funding options for senior housing and long-term care services. Senior care can range from a few hours a week of personal care or companionship from an in-home care provider, to full-time in-home care, to skilled nursing care in a nursing home. Many who have not done their research mistakenly believe that Medicare is the answer for long-term care.

In reality, it covers only a very narrow range of costs. It is important that you understand ahead of time the benefits and limits of Medicare, so you adequately prepare for senior care needs. In-home care is generally far less expensive, but costs vary greatly, depending on where you live, the level of care and hours of service required each week.

How will you pay for long-term care? Options include Medicare, Medicaid (if you qualify), long-term care insurance, Veterans Administration benefits and out of pocket (from your savings and assets). Medicare As previously mentioned, Medicare applies to long-term care in limited circumstances, such as immediately following a hospital stay.

Medicare covers short-term, physician-prescribed home health care for skilled nursing; physical, occupational and speech therapy; medical social services; and assistance with bathing, feeding and other personal care.

Medicaid and State Programs Medicaid, the largest public payer for long-term care, will (if you qualify) pay for nursing home care and other costs that Medicare does not cover. It may also cover some in-home care services. Those who receive Supplemental Security Income (SSI) are likely to qualify for Medicaid automatically. You can also qualify if you have limited income and assets. Eligibility guidelines vary by state.

Assets considered for eligibility generally do not include homes, cars, household furnishings or burial plots. In some cases you may still qualify if your income exceeds your state’s eligibility level. And in several states, seniors may qualify for Medicaid after they have spent their income and assets on nursing home or other health care expenses. This is commonly referred to as the Medicaid “spend down.”Older adults who do not qualify for larger government programs like Medicaid may find they qualify for state programs.

Information on these can be found through local Area Agencies on Aging. Long-Term Care Insurance Long-term care insurance helps seniors pay the costs of long-term care, preventing the depletion of life savings for extended care.

However, coverage is expensive. Premiums increase with the age of the purchaser. According to The Wall Street Journal, a 55-year-old single adult can expect to pay $2,065 a year for $162,000 in benefits with 3-percent compound inflation protection (this increases your benefits to compensate for inflation).

If you earn ample income, premiums can be affordable, but you need to make sure you will still be able to pay the premium after you retire. And even if you can, you may not be able to justify the expense if you have the resources to pay for care out of pocket.

Your financial planner can help guide you in this decision. Not all long-term insurance policies are created equal, so be sure you know what you are buying. Some policies cover only specific types of long-term care, while others will cover a variety, such as nursing home, assisted living or in-home care. Know up front to what degree premiums may increase over time. Also be aware that premiums vary by the number of years covered under the policy.

Lifetime coverage can be very expensive. Many long-term care policies have an elimination period — that is, a waiting time during which the covered individual must pay for his own care. The longer the elimination period, the lower the premium. Know what percentage of daily care costs your policy will cover, and realize that inflation will increase the costs.

Inflation protection is commonly sold as a rider for long-term care insurance. Policies vary in how they define eligibility for benefits.

Some plans, for instance, state that a senior qualifies when she can no longer perform certain defined activities of daily living. Veterans Administration Aid and Attendance Pension Benefit Veterans and their surviving spouses may qualify for Veterans Administration (VA) benefits to cover some of the cost of in-home care. A veteran or a surviving spouse of a veteran who served at least 90 days on active duty with one day during a period of war may be eligible for the VA’s non-service connected disability pension.

Paying Out of Pocket for Long-Term Care Seniors and their families often must tap into savings and assets to pay for long-term care, as many cannot afford long-term care insurance, many do not qualify for Medicaid and Medicare coverage is very limited.

The cost of care will depend greatly on the amount of care the senior requires. To get an idea of what the expense could be, research nursing home costs in your area, then calculate the total for a four-year stay.

But actual costs cannot be predicted, as persons with Alzheimer's disease or other forms of dementia often need care for many more years. In comparison, in-home care expenses are often much less. You can find out by researching costs in your area.

In doing so, you may also need to get estimates of the cost of home adaptations to help you stay in your home. The Financial Impact of In-Home Care At first glance, the cost of professional in-home care may look greater than it truly is. That is, until family caregivers honestly consider the value of the time and financial sacrifices made to care for a loved one.

If you are a family caregiver, you understand that the responsibility requires a considerable amount of your time — time and attention your loved one deserves. As a caregiver, you get phone calls at all times, day and night. You coordinate transportation to and from medical appointments, grocery shopping and other errands.

You have another home to clean. You are the one who helps pay bills, provides companionship and takes care of other tasks as needed.

And you do this in addition to the other responsibilities you have, such as your job and family. In order to accomplish everything that needs to be done, you may have to reduce your hours at work.

Maybe you have cut back to part-time employment and passed up a promotion. These lost opportunities have a real impact on your financial situation now and in the future, specifically when it comes time to retire. Considering these lost opportunities, take another look at the quotes you have been given to hire a professional in-home care provider.

With this in mind, the cost of having a qualified and insured home care agency assume caregiving tasks does not seem that high, does it? When you work with a reputable in-home care agency, you will still be in charge of the care your loved one receives.

You just will not be responsible for the time-consuming, day-to-day caregiving responsibilities. If you have been avoiding it, now is the time to determine the financial impact that home care makes on your life. You may find that allowing others to do the job is a smart financial decision.

re is Medicare is a federal health insurance program for retirees age 65 or older and certain disabled people. Medicare Part A covers inpatient hospital care, some skilled nursing facility care and hospice care. Medicare Part B covers physician care, diagnostic x-rays and lab tests, and durable medical equipment.

Learn More About Turning Age 65 and Medicare

GIC Medicare Guideline - When to Enroll in Medicare. What Medica

Medicare Part D is a federal prescription drug program. When to enroll in Medicare Part A and Part B if you have GIC health coverage This depends on your employment status with the state or a participating GIC municipality: If you, the insured, continue working for the state or a participating GIC municipality at age 65 or over, you and your covered spouse should only enroll in free Medicare Part A if eligible.

Defer Part B until you, the insured, retire. If retiring, and you or your covered spouse is age 65 or over, the family member (s) age 65 or over should apply for Medicare Part A and Part B up to a month before your retirement.

You and/or your spouse age 65 or over will receive a Medicare enrollment package from the GIC approximately two to three weeks after the GIC is notified by your GIC Coordinator of your retirement.

Be sure to respond to the GIC by the due date noted in the package. If retired, when you or your covered spouse turns age 65, apply for Medicare Part A and Part B up to three months before your 65th birthday. You or your spouse turning age 65 will receive a Medicare enrollment package from the GIC approximately three months before your 65th birthday to make your Medicare health plan selection.

Be sure to respond to the GIC by the due date noted in the package. If you do not enroll in Medicare Part B within the required time, or cancel Part B and re-enroll at a later date, you will be required to pay federal government penalties.

Also, you may be ineligible for health coverage through the GIC. If you are retired, but not age 65 and your spouse is turning age 65Your spouse should visit Social Security’s website or your local Social Security Office for confirmation of Social Security and Medicare eligibility. If eligible for Part A for free, he/she must enroll in Medicare Part A and Part B to continue coverage with the GIC through a GIC Medicare supplemental plan. See the under/over age 65 section of the Benefit Decision Guide, available on our website, for your health plan combination options. This information is also included in the Medicare Plan enrollment package that will be mailed to your spouse.

How to find out whether or not you are eligible for Medicare Part A and Part B benefits if you are retired and under age 65 and your spouse or you are disabled If you or your spouse is disabled and receiving Social Security disability benefits, Social Security will automatically enroll you or your spouse in Medicare Part A and Part B on the 25th month of receiving benefits; contact Social Security about Medicare-eligibility. If eligible, contact the GIC at 617.727.2310 ext. 6 to request a Medicare Plan enrollment package.

Why you need to know about Medicare if you have been a state employee for your entire career and have never contributed to Social Security You may still be eligible for Medicare benefits.

For example, if you are married, you may be eligible for Medicare through your spouse. When you turn age 65, visit Social Security’s website or call Social Security to apply.

If you are not eligible for Medicare, the GIC will require a copy of your Denial Letter from the Social Security Administration that you are not eligible and you will remain in a GIC non-Medicare health plan. The cost of Medicare Part BThe premium is set by the Centers for Medicare and Medicaid Services (CMS).

Contact Medicare (1.800.633.4227) for the current premium cost. How to pay for Medicare Part BIn most cases, the federal government will deduct the Medicare Part B premium from your monthly Social Security check.

If you or your spouse is not eligible for a Social Security check, the federal government will bill you quarterly for the Medicare Part B premium. What to do if Social Security has informed you (or your covered spouse) that you (or your covered spouse) is only eligible for Medicare Part BYou (or your covered spouse) will not be eligible for a GIC Medicare Supplemental Plan until you (or your covered spouse) are eligible for Medicare Part A for free.

You (or your covered spouse) will remain in a non-Medicare GIC plan. What are the consequences if you cancel or do not pay Medicare Part B if you are in a GIC Medicare Plan If you cancel or do not pay Medicare Part B, the GIC is required to terminate your GIC health coverage.

This would mean that you would only have Medicare Part A coverage for inpatient hospital care. You would no longer have coverage for: Physician office visits Prescription drugs Outpatient mental health/substance abuse care Outpatient surgery X-rays and diagnostic tests Hearing aids If you wanted to later reinstate your Medicare Part B coverage, you would be subject to federal late enrollment penalties and would have to wait for Medicare’s January through March enrollment period followed by the GIC’s spring annual enrollment period to get back into a GIC health plan.

So, consider the consequences before you cancel or don’t pay Medicare Part B. Medicare only health care coverage is not recommended“Medicare only” coverage is not recommended as it has coverage limitations. To ensure comprehensive coverage, Medicare retirees should enroll in a Medicare health plan sponsored by the GIC as a supplement to their Medicare coverage.

Medicare as a “stand alone” insurance does not provide comprehensive or complete coverage. It is not recommended.

See previous question for details. The documents you must provide to the GIC with the Medicare Plan Enrollment form you receive from the GIC when you retire at age 65 or over or are retired and you or your covered spouse turns age 65Indicate your GIC Medicare plan options and fill in your Medicare Claim Number on the form, sign and return by the date noted on the form.

If you and/or your spouse are over age 65 and not eligible for Medicare we will need the following documentation: Social Security Denial Letter stating that you and/or your spouse is not eligible for Medicare Part A for free. When your GIC Medicare Plan go into effect The GIC determines the Medicare Plan effective date based on receipt of completed forms. The effective date of a GIC Medicare Advantage Plan (Fallon Senior Plan and Tufts Medicare Preferred) is determined by the Centers for Medicare and Medicaid (CMS).

Once you are enrolled, you will receive an ID card from your Medicare health plan. What happens to your spouse's coverage if you enroll in a GIC Medicare supplemental plan Your spouse will continue to be covered under in a GIC non-Medicare plan if he/she is under age 65 until he or she becomes eligible for Medicare.

You and your spouse must join the same health plan. See the Benefit Decision Guide for under and over age 65 health plan combination options.

If your spouse is over age 65, he/she must enroll in the same Medicare supplemental plan that you have joined. What you need to do at age 65 if your spouse or yourself was not eligible for Medicare Part A for free, but now, you and your spouse have subsequently become eligible for Medicare Part A for free You or your spouse must notify the GIC in writing when you become eligible for Medicare Part A.

The GIC will notify you of your coverage options. Failure to do this may result in loss of GIC coverage. Keep in mind that Medicare’s rules allow you to buy Part B at age 65, even if you are not eligible for free Medicare Part A. If your spouse is at least age 62 when you approach age 65, you may be eligible for free Part A due to your spouse’s eligibility.

Under Medicare’s rules, failure to apply for Part B when you become eligible may mean a penalty for late enrollment. Contact Social Security for details. You may want to purchase Medicare Part B if you are retired and are not eligible for Medicare Part A for free, but are eligible for Medicare Part BThe GIC does not require you to enroll in Medicare Part B if you are not eligible for Medicare Part A for free.

However, if you may be eligible for Medicare Part A in the future (for example, you have a younger spouse) you may want to enroll in Part B to avoid a Medicare penalty later on. Contact Social Security for details. You need to enroll in Medicare Part A and Part B if you are age 65 or over and eligible if you are retired with GIC health insurance, but you are working elsewhere Because you have health insurance through the GIC as a retiree, you will be enrolling a GIC Medicare plan to continue coverage.

Which ID card you should present to a doctor’s office or hospital if you are an active state employee age 65 or over and have a Medicare card with Part A only When receiving services at a hospital or doctor, present your GIC health plan card (not your Medicare card) to ensure that your GIC health plan is charged for the visit.

If you are still working and are age 65 or over, your GIC health plan is your primary health insurance provider; Medicare (if you have it) is secondary.

You may need to explain this to your provider if he/she asks for your Medicare card. What to do when Medicare says they are not your primary carrier yet you are retired, age 65 or over and have a Medicare supplemental plan through the GICYou must call Medicare at 1.800.633.4227 to correct the coordination of benefits.

How to find out about GIC Medicare plan options When you retire at age 65 or over or if you (the insured) are retired and turn age 65/or your covered spouse turns age 65, the GIC will send you approximately three months before the 65th birthday a Medicare enrollment package that includes information about your health plan options.

How to enroll in a GIC Medicare plan Complete and return the Medicare Plan Enrollment form the GIC sends to you when you retire and you and/or your spouse is age 65 or over or when you are retired and you or your covered spouse turns age 65.

Be sure to return the completed form by the due date indicated on the form. If enrolling in Harvard Medicare Enhance, Health New England Med Plus, Tufts Medicare Complement or Uni Care Indemnity Plan/Medicare Extension (OME), you must also complete and return the Medicare Part D Opt-in Form. When to change GIC Medicare plans You may only change your GIC Medicare plan during the GIC’s spring annual enrollment period or if you move out of a GIC HMO Medicare plan's service area.

How to change Medicare plans during the GIC’s annual enrollment period or if you move out of your Medicare HMO plan's service area Complete and return to the GIC a Retiree/Survivor Enrollment and Change Form (Form-RS).

Changes can also be made at a GIC health fair. If enrolling in Harvard Medicare Enhance, Health New England Med Plus, Tufts Medicare Complement or Uni Care Indemnity Plan/Medicare Extension (OME), you must also complete and return the Medicare Part D Opt-in Form. If you are enrolling in Fallon Senior Plan, the plan will send you an application to complete and return. If you are currently in a Medicare Advantage HMO plan— - Fallon Senior Plan or Tufts Medicare Preferred—, you must dis-enroll from the plan by also sending to the GIC a completed Medicare Advantage/EGWP Plan dis-enrollment form.

The plan will notify you and the GIC of the effective date of the dis-enrollment. How to calculate your monthly premium rates Using the rate section of our website, add the following: For an insured and spouse on Medicare Find the premium for the Medicare plan in which you are enrolling and double it for your monthly rate.

For a Retiree and Spouse Coverage if Under and Over Age 65 1. Find the premium for the Medicare Plan in which the Medicare retiree or spouse will be enrolling 2.

Find the individual coverage premium for the Non-Medicare Plan in which the Non-Medicare retiree or spouse will be enrolling. 3. Add the two premiums together; this is what you will pay monthly. For other coverage combinations, contact the GIC at 617.727.2310 ext. 6. If you are an active employee with GIC health coverage who is age 65 or over, you should not enroll in Medicare Part DIf you are a retiree with GIC health coverage, you should not enroll in a non-GIC Medicare Part D plan No.

For most GIC Medicare enrollees, the drug coverage you currently have through your GIC health plan is a better value than a basic Medicare Part D drug plan.

Therefore, you should not enroll in a non-GIC Medicare Part D plan. Effective July 1, 2017, all GIC Medicare plans automatically include Medicare Part D coverage.

Do not enroll in a non-GIC Medicare Part D plan. If you enroll in another Medicare Part D drug plan, the Centers for Medicare & Medicaid Services will automatically dis-enroll you from your GIC health plan, which means you will lose your GIC health, behavioral health, and prescription drug benefits. If you have extremely limited income and assets, you may be eligible for prescription drug subsidies through the Extra Help program. Contact Medicare at 1-800-MEDICARE (1-800-633-4227) or Social Security (1-800-772-1213) for more information.

If your adjusted gross income, as reported on your federal tax return, exceeds a certain amount, Social Security will impose a monthly additional fee called IRMAA (Income-Related Monthly Adjustment Amount). Visit medicare.gov for more information. Social Security will notify you if IRMAA applies to you.

How to avoid paying a late enrollment penalty for Medicare Part DThe Medicare Part D Late Enrollment Penalty (LEP) is the amount that Medicare requires a person to pay if he/she: • Did not enroll in a Medicare prescription drug plan when first eligible for Medicare; or • Did not have creditable prescription drug coverage – coverage at least as good as Medicare’s standard plan; or • Had a break in coverage of more than 63 consecutive days.

The GIC’s retiree prescription drug coverage meets or exceeds the Medicare Part D coverage standard and is therefore considered creditable coverage. See your health plan handbook on your plan’s or the GIC’s website for a Creditable Coverage notice. Note that if you decide to enroll in a non-GIC Medicare Part D plan that cancels your GIC coverage, you may be responsible for the Medicare Part D late enrollment penalty if you later wish to re-enroll in GIC Part D coverage.

BERKS MEDICAL EQUIPMENT LBN SJH SERVICES CORPORATIONDurable Medical Equipment & Medical Supplies A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient?s use in the home and that are usable for an extended period of time.

BERKS MEDICAL EQUIPMENT LBN SJH SERVICES CORPORATION

Share Tweet Reviews Edit my contact information Contact Information BERKS MEDICAL EQUIPMENT LBN SJH SERVICES CORPORATION10B WINGCO LNREADING, PA 19605-9783 Phone: 610-916-1871 Fax: 610-916-8948 Website: Specialty Taxonomy Code Specialty Code Provider Type Durable Medical Equipment & Medical Supplies332B00000X54 Other Medical Supply Company Oxygen Equipment & Supplies332BX2000XB1 Oxygen supplier Parenteral & Enteral Nutrition332BP3500XIndicates primary specialty Edit contact information NPI Profile & details for BERKS MEDICAL EQUIPMENTNPI Number 1538137427LBN Legal business name SJH SERVICES CORPORATIONDBA Doing business as BERKS MEDICAL EQUIPMENTAuthorized official DAVID LIM - (CHIEF FINANCIAL OFFICER)Entity Organization Organization subpart 1 No Enumeration date 03/08/2006Last updated 11/06/2012 - About 5 years ago Identifiers PA License # 3000008951PA Medicaid 10077397500071Some organization health care providers are made up of components that furnish different types of health care or have separate physical locations where health care is furnished. These components and physical locations are not themselves legal entities, but are part of the organization health care provider (which is a legal entity).

A covered organization provider may decide that its subparts (if it has any) should have their own NPI numbers. If a subpart conducts any HIPAA standard transactions on its own (e.g., separately from its parent), it must obtain its own NPI number.

Submit Review Reviews for BERKS MEDICAL EQUIPMENTThere are currently no reviews for BERKS MEDICAL EQUIPMENT Be the first to post a comment or review .

Read our reviews / comments about this provider to help you decide if they are right for you. Share your experience by posting a comment or review about this provider to help others decide which is right for them.

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"Medicare Part BOriginal Medicare is made up of two parts: Medicare Part A provides hospital insurance, while Medicare Part B offers medical insurance. Together, these two parts equal Original Medicare, the federally administered health-care program for seniors and certain disabled individuals. Medicare Part B covers medically necessary services and supplies, including doctor visits, preventive care, and durable medical equipment.

Medicare Part B

What does Medicare Part B cover? The following are some examples of what Medicare Part B covers: Ambulance services: transport and travel to and from certain locations Chemotherapy Chiropractic care for spine manipulation to correct a subluxation (in medically necessary circumstances, when performed by a chiropractor or other qualified health-care provider)Diagnostic tests and lab work Doctors services, such as office visits Durable medical equipment (DME)Home health services Outpatient physical, speech, and occupational therapy services provided by a Medicare-certified physical, speech, or occupational therapist Outpatient mental health services, including partial hospitalization Preventive-care services, including screenings and vaccines""Welcome to Medicare"" and yearly ""Wellness"" physical exams X-rays If you're enrolled in a Medicare Advantage plan, you'll still be covered for the same Medicare Part A and Part B coverage you would have had under Original Medicare.

Medicare Advantage plans are required to provide at least the same level of coverage as Original Medicare, so you'll have the same baseline level of benefits that you would have under the federal program.

In addition, your Medicare Advantage plan may cover other benefits to keep you healthy, such as routine vision or dental, wellness programs, or prescriptions drugs.

How do I get Medicare Part B? To be eligible for Medicare, you must be a United States citizen or legal permanent resident of at least five continuous years and 65 years or older.

You can also be eligible for Medicare before 65 if you've been receiving disability benefits from Social Security or the Railroad Retirement Board for at least two years, or if you have end-stage renal disease or amyotrophic lateral sclerosis (also known as Lou Gehrig's disease).

Like other parts of Medicare, there are rules concerning when you're eligible and when you can sign up for coverage. If you're already receiving retirement benefits before you turn 65, you may be automatically enrolled in Medicare Part A and/or Part B the month that you turn 65. You're also automatically enrolled in Medicare if you've been receiving Social Security or Railroad Retirement Board disability benefits for at least two years; you'll be automatically enrolled in the 25th month of disability benefits. Those who qualify for Medicare because of end-stage renal disease must manually sign up for Part B.

You can also sign up for Medicare Part B during the following periods: Initial Enrollment Period (IEP): This is when you are first eligible to enroll in Medicare, either by turning 65 or through disability.

If you qualify because of age, your Initial Enrollment Period starts three months before you turn 65 and lasts for seven months. If you qualify for Medicare because of disability, your Initial Enrollment Period starts three months before your 25th month of disability benefits from Social Security or the Railroad Retirement Board and lasts seven months.

General Enrollment Period (GEP): If you missed your Initial Enrollment Period, you can also enroll in Medicare Part B during this period, which occurs from January 1 to March 31 annually. If you enroll in Medicare Part B during the General Enrollment Period, your coverage will go into effect on July 1 of the year that you signed up.

If you didn't enroll in Medicare Part B when you were first eligible, you may have to pay a late-enrollment penalty, and your Medicare Part B premium may be 10% higher for every 12-month period that you could have had Medicare Part B, but decided not to get it.

Special Enrollment Period (SEP): You may opt to delay your Medicare Part B enrollment if you or your spouse are working and have group health coverage based on current employment. When you or your spouse retires and you lose your group health coverage, you will be given a Special Enrollment Period to enroll in Medicare Part B. The Special Enrollment Period is the eight-month period following the month when the employer coverage ends or you stop working (whichever happens first).

You can enroll any time you and your spouse remain covered by the group health plan or during the Special Enrollment Period. You can enroll in Medicare Part B through Social Security in the following ways: Online at SSA.gov. If you're not yet ready to apply for retirement benefits, you can apply for Medicare only. In-person at a local Social Security office.

By calling Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778. Social Security representatives are available Monday through Friday, from 7AM to 7PM. If you worked at a railroad, you can apply for Medicare through the Railroad Retirement Board, not Social Security. Contact the Railroad Retirement Board to enroll at 1-877-772-5772 (TTY users, call 1-312-751-4701); Monday through Friday, from 9AM to 3:30PM.

Medicare Part B costs While some people may be eligible for premium-free Medicare Part A if they've worked at least 10 years (40 quarters) and paid Medicare taxes during that time, most beneficiaries must pay a monthly premium for Medicare Part B insurance unless they qualify for low-income assistance.

This premium amount may change from year to year. Visit Medicare.gov to learn how much you may have to pay for your Medicare Part B premium. If your income falls above a certain threshold, you may have to pay a higher amount for Medicare Part B coverage. This is known as an Income Related Monthly Adjustment Amount (IRMAA), which is an extra amount you'll pay on top of your monthly Part B premium.

Social Security will contact you if this applies to you. In addition, you may owe certain out-of-pocket expenses for Medicare Part B-covered services, including copayments, coinsurance, and the Part B annual deductible. Once you've met your yearly deductible, you'll usually pay 20% of the Medicare-approved amount for most medical services and supplies.

However, this may vary, depending on the specific service or equipment. For the most up-to-date Medicare Part B cost information, visit Medicare.gov. Do you have questions about what Medicare Part B covers? Or perhaps you're interested in finding additional benefits beyond Original Medicare, such as through a Medicare Advantage plan. If you'd like to discuss your Medicare coverage options with a licensed insurance agent, call e Health today to learn about Medicare plan options that may work for your situation. "

In order for an item to be covered by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC), it must fall within one of ten benefit categories. Medicare Part B covered services processed by the DME MAC fall into the following benefit categories specified in Section 1861 (s) of the Social Security Act:

Noncovered Items

Durable medical equipment (DME)Prosthetic devices Leg, arm, back and neck braces (orthoses) and artificial leg, arm and eyes, including replacement (prostheses)Home dialysis supplies and equipment Surgical dressings Immunosuppressive drugs Erythropoietin (EPO) for home dialysis patients Therapeutic shoes for diabetics Oral anticancer drugs Oral antiemetic drugs (replacement for intravenous antiemetics)Some items may not meet the definition of a Medicare benefit or may be statutorily excluded. The items listed below will always be denied as non-covered. The Medicare National Coverage Determinations (NCD) Manual provides a list of items that are noncovered with the reason for denial.

The following items will be denied as noncovered when submitted to the DME MAC. Search for a HCPCS XHCPCS Code Brief Description A4210 Needle-free injection device, each A4250 Urine test or reagent strips or tablets (100 tablets or strips)A4490 Surgical stockings above knee length, each A4495 Surgical stockings thigh length, each A4500 Surgical stockings below knee length, each A4510 Surgical stockings full-length, each A4520 Incontinence garment, any type, (e.g.

brief, diaper), each A4554 Disposable underpads, all sizes A4575 Topical hyperbaric oxygen chamber, disposable A4627 Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler A6000 Non contact wound-warming wound cover for use with the non contact wound-warming device and warming card A6530 Gradient compression stocking, below knee, 18-30 mm Hg, each A6533 Gradient compression stocking, thigh length, 18-30 mm Hg, each A6534 Gradient compression stocking, thigh length, 30-40 mm Hg, each A6535 Gradient compression stocking, thigh length, 40-50 mm Hg, each A6536 Gradient compression stocking, full length/chap style, 18-30 mm Hg, each A6537 Gradient compression stocking, full length/chap style, 30-40 mm Hg, each A6538 Gradient compression stocking, full length/chap style, 40-50 mm Hg, each A6540 Gradient compression stocking, waist length, 30-40 mm Hg, each A6541 Gradient compression stocking, waist length, 40-50 mm Hg, each A6542 Gradient compression stocking, custom made A6543 Gradient compression stocking, lymphedema A6544 Gradient compression stocking, garter belt A6549 Gradient compression stocking, not otherwise specified A9270 Noncovered item or service A9275 Home glucose disposable monitor, includes test strips A9276 Sensor; invasive (e.g.

subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply A9277 Transmitter; external, for use with interstitial continuous glucose monitoring system A9278 Receiver (monitor); external, for use with interstitial continuous glucose monitoring system A9280 Alert or alarm device, not otherwise classified A9281 Reaching/grabbing device, any type, any length, each A9282 Wig, any type, each A9300 Exercise equipment B4100 Food thickener, administered orally, per ounce E0172 Seat lift mechanism placed over or on top of toilet, and type E0191 Heel or elbow protector, each E0203 Therapeutic lightbox, minimum 10,000 lux, table top model E0220 Hot water bottle E0230 Cap or collar E0231 Non-contact wound warming device (temperature control unit, AC adapter and power cord) for use with warming card and wound cover E0232 Warming card for use with the non-contact wound warming device and non-contact wound warming wound cover E0240 Bath/shower chair, with or without wheels, any size E0241 Bath tub wall rail, each E0242 Bath tub rail, floor base E0243 Toilet rail, each E0244 Raised toilet seat E0245 Tub stool or bench E0246 Transfer tub rail attachment E0247 Transfer bench for tub or toilet with or without commode opening E0248 Transfer bench, heavy duty, for tub or toilet with or without commode opening E0270 Hospital bed, institutional type includes: oscillating, circulating and stryker frame with mattress E0273 Bed board E0274 Over-bed table E0315 Bed accessory: board, table, or support device, any type E0481 Intrapulmonary percussive ventilation system and related accessories E0625 Patient lift, bathroom or toilet, not otherwise classified E0637 Combination sit to stand system, any size including pediatric, with seatlift feature, with or without wheels E0638 Standing frame system, one position (e.g.

upright, supine or prone stander), any size including pediatric, with or without wheels E0641 Standing frame system, multi-position (e.g.

three-way stander), any size including pediatric, with or without wheels E0642 Standing frame system, mobile (dynamic stander), any size including pediatric E0700 Safety equipment (e.g., belt, harness or vest)E0710 Restraints, any type (body, chest, wrist or ankle)E0936 Continuous passive motion exercise device for use other than knee E1300 Whirlpool, portable (overtub type)J1055 Injection, medroxyprogesterone acetate for contraceptive use, 150 mg J3520 Edetate disodium, per 150 mg J3535 Drug administered through a metered dose inhaler J3570 Laetrile, amygdalin, vitamin B-17J8499 Prescription drug, oral, nonchemotherapeutic, NOSJ8515 Cabergoline, oral, 0.25 mg L0210 Thoracic rib belt L1800 Knee orthosis, elastic with stays, prefabricated L1815 Knee orthosis, elastic or other elastic type material, with condylar pads, prefabricated L1825 Knee orthosis, elastic knee cap, prefabricated L1901 Ankle orthosis, elastic, prefabricated L3651 Shoulder orthosis, single shoulder, elastic, prefabricated L3652 Shoulder orthosis, double shoulder, elastic, prefabricated L3700 Elbow orthosis elastic with stays, prefabricated L3701 Elbow orthosis, elastic, prefabricated L3909 Wrist orthosis, elastic, prefabricated L3911 Wrist hand finger orthosis, elastic, prefabricated L3215 Orthopedic footwear, ladies shoes, oxford, each L3216 Orthopedic footwear, ladies shoes, depth inlay, each L3217 Orthopedic footwear, ladies shoes, hightop, depth inlay, each L3219 Orthopedic footwear, mens shoes, oxford, each L3221 Orthopedic footwear, mens shoes, depth inlay, each L3222 Orthopedic footwear, mens shoes, hightop, depth inlay, each L7600 Prosthetic donning sleeve, any material, each L7900 Male Vacuum Erection System L7902 Tension Ring, for vacuum erection device, any type, replacement only, each Q0144 Azithromycin dehydrate, oral, capsules/powder, 1 gram V2025 Deluxe frame V2600 Hand held low vision aids and other nonspectacle mounted aids V2610 Single lens spectacle mounted low vision aids V2615 Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system V2702 Deluxe lens feature V2760 Scratch resistant coating, per lens V5336 Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid)Resource CMS Internet Only Manual Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 280.1Last Updated Jan 29, 2018

"Consumable and Durable Medical Consumable Medical Supplies are nondurable supplies and items that enable activities of daily living. Durable Medical Equipment include some specified, prescriptive equipment required by the individual. Consumable Medical Supplies Requirements and Service Limitations

WaiverProvider.Com

Durable Medical Supplies Requirements and Service Limitations Woodbury Products- All of Florida Woodbury Products provides diapers, wipes, and other consumable medical supplies. They will send customers samples of their products. Woodbury also delivers right to the customer's door. Since 1980 we have focused on being the foremost experts in SOLVING the needs of those who wrestle with incontinence. For almost 35 years we have worked to help thousands and thousands of individuals, family members, and caregivers with their incontinence needs.

Our vision is to maintain the quality of life and provide dignity and relief for those who suffer from common, yet distressful health issues. We are People with a Purpose. 1-888-444-3331Park Shore Pharmacon is a long term care pharmacy providing specialized medication services and consumable medical supplies to organizations in the state of Florida. Park Shore offers specialty medication packaging; laser-printed MARs; a ""color-coded"" pharmacy program; free delivery; electronic MAR programs; consumable medical supplies; medication regimen reviews and more.

Please contact Kristen, kristen@parkshoredrug.com for more information on how to get started with Park Shore's premier pharmacy program today! (954) 874-4646All Florida Medical Supply All Florida Medical Supplies is the premiere provider of medical supplies sales, rentals, and services for customers in Citrus, Hernando, Lake Marion, Pasco, Pinellas, and Sumter counties.

With over 45 years combined in medical equipment and supplies, our staff has the expertise needed to make sure you get the proper supplies when you need them. Call Tammy Mckenzie at 352-683-4236Email: Tammy Mckenzie@tampabay.rr.com Visit our website: All Florida Medical.com Aldo Surgical carries DME and Waiver products for incontinence and colostomy.

We offer a large variety of bathroom aids, lift chairs, and walkers. Licensed personnel dispense orthopedic and mastectomy products, diabetic shoes and compression stockings. Our RESNA certified wheelchair technician can fit any type of wheelchair or scooter. Hialeah Gardens FL. 305-557-2835 Miami, FL. 305-552-5626 Visit our website at: aldosurgicalsupply.com Diaper Depot USA LLCAt DIAPER DEPOT USA we specialize in the distribution of Consumable Medical Supplies across Palm Beach County, Broward & Treasure Coast.

By partnering with many different suppliers and manufacturers, we are able to provide our customers with all major national brands of Briefs, Protective Underwear, Underpads , Wipes etc….. Our mission is to make our customers as comfortable as possible each and every day by providing them with superior customer service so our customers get their supplies quickly & efficiently.

We are Med-Waiver Providers! !932 N. Dixie Highway, #2. Lake Worth, FL 33460Telephone: (561)308-3570 Email: diaperdepotusa@yahoo.com Website: www.diaperdepotusa.net Advance Care Medical Supply Now offering ABA services in Miami-Dade & Broward County We are happy to let you know that Advance Care Medical Supply Inc is here to help you and your clients.

We take pride in making sure your clients get the best incontinence supplies. Our full range of incontinence products protect you when you need it most and give you the peace of mind to live your life to the fullest. We are proud to have built a reputation for providing quality Incontinence Supplies products and services. We are totally committed to delivering the high level of quality care you desire and expect from us.

Office Phone Number: (305) 256-1653 Cell Phone Number: (786) 260-7459 Email: advmedsupplies@hotmail.com Back to Top Back to Home Page Put Your Listing Here!Call Aaron Nangle at 727-841-8943 to find out how. Waiver Providers, you can add your listing even if you don't have a website. We provide a free one page ""web flyer"" and free hosting, with your membership. Not a publication of The Agency For Persons With Disabilities "

The Durable Medical Equipment Aid Society (The DME) is a locally based, non-profit organization that supports and promotes the re-use of gently used durable medical equipment and makes that equipment available, free of charge, to these individuals.

The DME Is A Locally Based, Non-profit Organization

Welcome to Our Website Thousands of individuals in Southern California who are elderly, or who have on-going physical limitations, or who become disabled due to illness or injury, have limited or no access to the wheelchairs, walkers, or other durable medical equipment that they need to assist in their daily living, their recovery from illness or injury, or to cope with on-going or recurring physical limitations due to limited financial or insurance resources.

The gift of a wheelchair can make the difference between being a prisoner in the home and being able to participate in activities with family and friends.

Join Our Campaign!Donate Now Support Durable Medical Equipment Aid Society. When you shop at smile.amazon.com,Amazon donates.

ce)Durable medical equipment not directly related to the home infusion (billed by HDME provider)Drugs not reference in the Fee Schedule or that are not related, as determined by BCBSNC, to Home Infusion Therapy (billed by pharmacy)

Important News

"Important News Back to Index HOME INFUSION THERAPY QUICK REFERENCE GUIDEDEFINITIONSHome Infusion Therapy: the administration of prescription drugs and solutions in the home via one of these routes: Intravenous • Intraspinal • Epidural • Subcutaneous Per Diem: per day allowance for filing certain HCPC codes.

Per diems are recognized by the number of hours the member receives the infusion and not by the calendar day. Continuous infusions for a period longer than 24 hours, but less than 48 hours are equal to one per diem.

Modifier 59 should be used to indicate conurrent infusion in conjunction with the SH or SJ, as appropriate. COVERED SERVICESHome infusion therapy requiring regular nursing services is to be billed in three components : Per Diem component (covering all home infusion services, equipment and supplies except the prescription drug and licensed nursing services) for each day the drug is infused.

Nursing component provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Drug component Provider agrees to only bill for the quantity of drug actually administered not unused mixed, compounded or opened quantities.

Provider agrees to bill only for those drugs referenced in the Fee Schedule. NON-COVERED AND ALL INCLUSIVE SERVICESThe following services may not be billed under home infusion and are not part of your Home Infusion Therapy contract with BCBSNC: Oral prescription drugs (billed by pharmacy)Aerosolized drugs (billed by pharmacy)Services to hospice patients being cared for by a contracting hospice provider (billed by hospi

Antihemophilic Agents (Factor Drugs) are not considered valid Home Infusion Therapy drugs. Members can acquire these drugs through a participating Specialty Pharmacy vendor. The following services are considered as included in the per diem rate and will not be reimbursed separately.

The per diem rate includes all services not included in the pharmaceutical or nursing service component.• Durable Medical Equipment • Solutions, Diluents and Flushes• Care Coordination & Patient Education • Administrative Services• Professional Pharmacy Services • Medical Supplies BILLING GUIDELINESBill using the CMS-1500 claim form. Use your appropriate National Provider Identifier. File claims after services have been provided.

Bill your typical retail charges for prescription drugs, infusion and nursing services. Miscellaneous codes are valid for use only if no suitable billing code is available and appropriate documentation is included. INVALID CODESThe following list of codes has been determined as invalid services under the home infusion therapy specialty. Please note, effective December 15, 2009, these codes will no longer be reimbursable under the home infusion therapy benefit.

Please note, this listing represents the top codes filed within the 2009 calendar year and is not considered to be an all-inclusive list.

CODE CODE DESCRIPTION CODE TYPEJ7192 Factor VIII recombinant, per IU Drug - Antihemophilic Agent90378 Rsv ig, im, 50mg Drug - Specialty Pharmacy J7193 Factor IX non-recombinant, per IU Drug - Antihemophilic Agent J7195 Factor IX recombinant, per IU Drug - Antihemophilic Agent J7189 Factor VIIa recombinant, per 1 mcg Drug - Antihemophilic Agent J7187 Von Willebrand factor, injection Drug - Antihemophilic Agent J7190 Factor VIII human, per IU Drug - Antihemophilic Agent J1642 Injection heparin sodium per 10 units Drug - Injection Q4080 Iloprost, inhalation solution Drug - Specialty Pharmacy J1950 Leuprolide acetate /3.75 MG Drug - Specialty Pharmacy J7050 Normal saline solution infusion Part of Home Infusion Therapy Per Diem J3240 Thyrotropin injection Drug - Specialty Pharmacy J3490 Drugs unclassified injection Misc Drug - No Description J7322 Synvisc inj per dose Drug - Injection A4216 Sterile water/saline, 10 ml Part of Home Infusion Therapy Per Diem J7799 Non-inhalation drug for DME Drug - DMEJ8499 Oral prescrip drug non chemo Drug - Oral J2323 Natalizumab injection Drug - Injection J7321 Hyalgan/supartz inj per dose Drug - Injection J1595 Injection glatiramer acetate Drug - Injection J0585 Botulinum toxin a per unit Drug - Specialty Pharmacy J7324 Orthovisc inj per dose Drug - Injection J7030 Normal saline solution infusion Part of Home Infusion Therapy Per Diem J7323 Euflexxa inj per dose Drug - Specialty Pharmacy J2353 Octreotide injection, depot Drug - Specialty Pharmacy J1630 Haloperidol injection Drug - Injection You can reference BCBSNC policies and procedures for Home Infusion Therapy in our Blue Book Provider Manual.

Codes requiring Prior Plan Approval are on our website at www.bcbsnc.com (under the ""Provider"" section).

Please check our website regularly for up to date information. This Home Infusion Therapy Quick Reference Guide is not a guarantee of payment. As with all services, claims for Home Infusion Therapy are subject to your Agreement with BCBSNC; to BCBSNC's policies and procedures, including BCBSNC's medical policies; and to the terms of each member's contract. The service must be a covered service as a condition for payment. If there is a conflict between the Home Infusion Therapy Quick Reference Guide and your Agreement with BCBSNC or to BCBSN's policies and procedures, the Agreement and policies and procedures will prevail as indicated therein. "

es. In addition to helping seniors pay for environmental accessibility adaptations (formal language for home modifications), some of these programs help pay for assistive technologies (formal language for durable medical equipment).

State Assistance Programs for Home Modifications for Aging in Place

"State Assistance Programs for Home Modifications for Aging in Place Page Reviewed / Updated - Jun. 2017Other Help for Home Modifications Find Financial Assistance for Care Locate Affordable Home Care Get Quote for Bath Modifications Table of Contents Overview Eligibility List of Programs Overview Approximately one-third of states have financial assistance programs, sometimes called nursing home diversion programs, whose objective is to prevent the unnecessary institutionalization of the elderly (in nursing homes paid for by Medicaid). To that end, these programs will help pay for home modifications that enable elderly and disabled persons to remain living in their hom

Typically, the types of modifications covered by these programs include addition of wheelchair ramps, bathroom re-models, installing stair-lifts, doorway widening, and kitchen modifications. These programs may include grants or loans, or sometimes a combination of grants and loans is provided. Eligibility Each state's program has different eligibility requirements. Clicking on the program name below will take visitors to a detailed program page, which discusses eligibility and benefits.

Generally speaking, there are the following types of eligibility requirements. Persons must be elderly or disabled. They must be living at home, renting a home, or living in the home of a caregiver. Stated otherwise, they cannot be eligible if they reside in assisted living or a nursing home.

Have annual or monthly income within the program's limits. Some programs also consider the applicant's total financial resources (their ""countable assets""). List of Programs It is unfortunate that not every state offers assistance programs. Many of those that do offer assistance do so only for care services and not for home safety modifications.

However, at last review as of June 2017, there were 47 programs in 27 different states. The following state based programs provide some level of financial assistance or services to help the elderly make home modifications to allow them to remain living in their homes.

Some programs listed here provide financial assistance, but not for a specific purpose. Click on any of the program names to learn more.

Non-Medicaid State Assistance Programs for Home Modifications for Aging – Updated Jun. 2017Alaska Senior Access Program Alzheimers Disease Related Dementias Mini-Grants Senior Benefits Arizona Non-Medical HCBSConnecticut Home Care for Elders Choices at Home Project Florida Community Care for the Elderly (CCE)Home Care for the Elderly (HC)Local Services Programs Georgia Non Medicaid HCBSHawaii Kupuna Care Illinois Home Accessibility Program Indiana CHOICESIowa Iowa Able Foundation Loan Program Senior Living / Case Management Program Kentucky Hart-Supported Living Program Maine Maine Home Repair and Elderly Grant Maine Caregiver Respite Maryland Accessible Homes for Seniors Massachusetts Massachusetts Home Care and Enhanced Community Options Programs Minnesota Alternative Care Consumer Support Grant Nebraska Assistive Technology/Home Modifications Service Disabled Persons and Family Support Nevada Assistive Technology for Independent Living New Jersey New Jersey Assistance for Community Caregiving New York RESTORE Program CSENorth Dakota SPEDOhio Elderly Services Program Pennsylvania Pennsylvania Assistive Technology Foundation Access Home Modification Program Options Program Rhode Island Home and Community Care Co-Pay Program Texas DADS Services to Assist Independent Living In-Home and Family Support Utah The Alternatives Program Vermont Home Access Program & Sue Williams Freedom Fund Washington DCSenior Citizens' Home Repair and Improvement DC Single Family Residential Repair Program Wisconsin AFCSPCommunity Options Program (COP)SSI Exceptional Expense Supplement Family Care and Family Care Partnership Wyoming Home Services Program (Wy HS) "

If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment: You may need to rent the equipment.

Your Medicare Coverage

Is my test, item, or service covered? Go Canes How often is it covered? Medicare Part B (Medical Insurance) covers canes as durable medical equipment (DME). Medicare doesn't cover white canes for the blind. Who's eligible? All people with Part B are covered. Your costs in Original Medicare

You may need to buy the equipment. You may be able to choose whether to rent or buy the equipment.

Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare.

If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them. It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment.

If suppliers don't accept assignment, there’s no limit on the amount they can charge you. Note To find out how much your test, item, or service will cost, talk to your doctor or health care provider.

The specific amount you’ll owe may depend on several things, like: Other insurance you may have How much your doctor charges Whether your doctor accepts assignment The type of facility Where you get your test, item, or service Related resources Where to get covered DME items More information about DMEReturn to search results

TRICARE also covers: Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. customization or attachments to the DME to accommodate your medical disability, when your physician has prescribed the equipment as medically necessary and appropriate.

Less/More Get My Plan Info Home What's Covered Health Care Durable Medical Equipment Print | Need Larger Text? Durable Medical Equipment Return to Search >Covered by TRICARE? Limits Yes Not all equipment is covered.

There are limits. Must be prescribed TRICARE covers durable medical equipment (DME) when prescribed by a physician. DME is defined as an item that: Can withstand repeated use;Primarily and customarily serves a medical purpose; and Generally is not useful to an individual in the absence of an injury or illness.

TRICARE covers DME that: Improves, restores, or maintains the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient's function or condition Maximizes the patient's function consistent with the patient's physiological or medical needs Provides the medically appropriate level of performance and quality for the medical condition present Is not otherwise excluded by the regulation and policy DME may be rented or purchased.

However, your regional contractor will decide if a DME should be rented or purchased based on whether it is more economical and appropriate.

Medically necessary covered accessories and attachments to a DME necessary to make the DME “serviceable” for a particular disability. For example, a car lift that is an accessory to a wheelchair. Repairs to equipment that you own when needed to make the item serviceable. Replacement of DME that you own when: There's a change in your physical condition,There's accidental damage to the DME, or The DME is inoperative and can't be repaired, or The U. S. Food and Drug Administration have declared the DME adulterated.

Duplicate items (those that serve the same purpose, but may not be an exact duplicate, such as a portable oxygen concentrator as a backup for a stationary oxygen generator) that are essential to provide a fail-safe, in-home, life-support system.

TRICARE may cover: Electric-powered, cart-type vehicles as an alternate to an electric wheelchair.

Benefits will not be extended for the use of both an electric-powered, cart-type vehicle. TRICARE doesn't cover: DME for a beneficiary who is a patient in a type of facility that ordinarily provides the same type of DME item to its patients at no additional charge in the usual course of providing its services is excluded.

DME available to the beneficiary from a military hospital or clinic DME with deluxe, luxury, or immaterial features, which increase the cost of the item to the government relative to similar item without those features. Routine periodic servicing, such as testing, cleaning, regulating, and checking which the manufacturer doesn't require be performed by an authorized technician.

Duplicate items of otherwise allowable DME to be used solely as a back-up to currently owned or rented equipment. Expendable items such as incontinent pads, diapers, ace bandages etc. Non-medical equipment (e.g., humidifier, electric air cleaners, exercycle, safety grab bars etc.).

Disclaimer: This list of covered services is not all inclusive. TRICARE covers services that are medically necessary and considered proven.

There are special rules or limits on certain services, and some services are excluded. Last Updated 2/27/2015Most Viewed Topics Dental Prescriptions Vision Mental Health Therapeutic Services Related Topics What You Should Know About Durable Medical Equipment Contact Us Call Us Find My Login Find a Claims Address Ask a Benefit Question File a Complaint Report Fraud and Abuse Health & Wellness Healthy Living Alcohol Awareness Tobacco Cessation Preventive Services FAQs Publications Resources Disaster Information Go Paperless My Military Health Records Multimedia Center Recoupment of Overpayments Rights and Responsibilities About Us News Center Changes Regions Partners Facts and Figures TRICARE and the Affordable Care Act TRICARE® Trademark and Branding Program For Providers TRICARE Provider Types What TRICARE Pays to Providers Uniformed Service ID Cards Dental Providers Provider Resources For Staff For Members of the Media For Vendors Email Updates Sign up to receive TRICARE updates and news releases via email.www.tricare.mil is an official website of the Defense Health Agency (DHA), a component of the Military Health System TRICARE is a registered trademark of the Department of Defense (Do D), DHA.

All rights reserved. The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations.

Such links are provided consistent with the stated purpose of this Do D website. Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs. Need to Submit a Claim? Send it to the correct claims address. Need Technical Help? Find the right contact info for the help you need. DHA Address7700 Arlington Boulevard Suite 5101 Falls Church, VA 22042-5101Privacy Policy Accessibility/Section 508Fraud & Abuse FOIANo FEAR Act USA.gov

ed TRICARE covers durable medical equipment (DME) when prescribed by a physician. DME is defined as an item that: Can withstand repeated use;Primarily and customarily serves a medical purpose; and Generally is not useful to an individual in the absence of an injury or illness.

Less/More Get My Plan Info Home What's Covered Health Care Durable Medical Equipment Print | Need Larger Text? Durable Medical Equipment Return to Search >Covered by TRICARE? Limits Yes Not all equipment is covered. There are limits. Must be prescrib

TRICARE also covers: Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. customization or attachments to the DME to accommodate your medical disability, when your physician has prescribed the equipment as medically necessary and appropriate. Medically necessary covered accessories and attachments to a DME necessary to make the DME “serviceable” for a particular disability.

For example, a car lift that is an accessory to a wheelchair. Repairs to equipment that you own when needed to make the item serviceable. Replacement of DME that you own when: There's a change in your physical condition,There's accidental damage to the DME, or The DME is inoperative and can't be repaired, or The U. S. Food and Drug Administration have declared the DME adulterated.

All rights reserved. The appearance of hyperlinks to external websites does not constitute endorsement by the DHA of these websites or the information, products or services contained therein. For other than authorized government activities, the DHA does not exercise any editorial control over the information you may find at other locations. Such links are provided consistent with the stated purpose of this Do D website. Some documents are presented in Portable Document Format (PDF).

A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs. Need to Submit a Claim? Send it to the correct claims address. Need Technical Help? Find the right contact info for the help you need. DHA Address7700 Arlington Boulevard Suite 5101 Falls Church, VA 22042-5101Privacy Policy Accessibility/Section 508Fraud & Abuse FOIANo FEAR Act USA.gov

es. Medigap insurance provides coverage for many of the co-pays and some of the co-insurance related to Medicare -covered hospital, skilled nursing facility, home health care, ambulance, durable medical equipment, and doctor charges.

Medigap

"From Wikipedia, the free encyclopedianavigation search This article needs attention from an expert in Medicine or United States.

Please add a reason or a talk parameter to this template to explain the issue with the article. Wiki Project Medicine or Wiki Project United States may be able to help recruit an expert. (February 2009)Medigap (also Medicare supplement insurance or Medicare supplemental insurance) refers to various private health insurance plans sold to supplement Medicare in the United Stat

Medigap's name is derived from the notion that it exists to cover the difference or ""gap"" between the expenses reimbursed to providers by Medicare Parts A and B for the preceding named services and the total amount allowed to be charged for those services by the United States Centers for Medicare and Medicaid Services (CMS). As of 2006, 18% of Medicare beneficiaries were covered by a Medigap policy. [1] Public-option Part C Medicare Advantage health plans and private employee retiree insurance provides a similar supplemental role for almost all other Medicare beneficiaries not dual eligible for Medicaid.

Contents [ hide ]1 Eligibility1.1 Medicare recipients under age 652 Products available3 Drug coverage4 Enrollment patterns5 References6 See also Eligibility [ edit]Medicare eligibility starts for most Americans when they turn 65 years old.

Those who have been on Social Security eligibility for 24 months can also qualify for Medicare Part A and Part B. A person must be enrolled in part A and B of Medicare before they can enroll in a Medigap plan. When a person turns 65 - or if they are older and new to Medicare Part B - they become eligible for Medigap open enrollment.

This period starts on the first day of the month you turn 65 and lasts for 6 months. During this period, a person can buy any Medigap plan regardless of their health.

[2]This is different than if someone is losing group coverage or retiring. When this occurs the person is eligible to exercise his or her ""Guarantee Issue"" right. With a Medigap guarantee issue right a person can buy a Medigap Plan A, B, C, F, K, or L that’s sold by any insurance company in their state.

In addition, the insurance company cannot deny or raise the premium due to past or current health conditions. Also, the insurance company must cover any pre-existing conditions. Instead of exercising the guarantee issue right a person can opt to go through the underwriting process in order to buy a * plan G or N. Once a person is outside their open enrollment period and or guarantee issue they can change their Medigap plan but they will be subject to health underwriting by the insurance company they are applying with.

[3]It is also important to know that monthly premiums apply, and plans may not be cancelled by the insurer for any reason other than non-payment of premiums/membership dues.

Furthermore, a single Medigap plan may cover only one person. Finally, Medigap insurance is not compatible with a Medicare Advantage plan.

You cannot have both a Medicare supplement and a Medicare Advantage plan at the same time. You can only have a Medigap plan if you are still on Medicare Part A and Part B and have not replaced your coverage with a Medicare Advantage Part C coverage. [4]Medicare recipients under age 65 [ edit]Recipients of Social Security Disability Insurance (SSDI) benefits or patients with end-stage renal disease (ESRD) are entitled to Medicare coverage regardless of age, but are not automatically entitled to purchase Medigap policies unless they are at least 65.

Under federal law, insurers are not required to sell Medigap policies to people under 65, and even if they do, they may use medical screening. However, a slight majority of states require insurers to offer at least one kind of Medigap policy to at least some Medicare recipients in that age group.

Of these states, 25 require that Medigap policies be offered to all Medicare recipients. In California, Massachusetts, and Vermont, Medigap policies are not available to end-stage ESRD patients.

[5] Part D deductible will go up for about 20% of Americans to over $150.00 a year. That's close to a 50% increase in 2016. Products available [ edit]Medigap offerings have been standardized by the Centers for Medicare and Medicaid Services (CMS) into ten different plans, labeled A through N, sold and administered by private companies.

Each Medigap plan offers a different combination of benefits. The coverage provided is roughly proportional to the premium paid. However, many older Medigap plans (these 'older' plans are no longer marketed) offering minimal benefits will cost more than current plans offering full benefits.

[6] The reason behind this is that older plans have an older average age per person enrolled in the plan, causing more claims within the group and raising the premium for all members within the group.

Since Medigap is private insurance and not government sponsored, the rules governing the sale and offerings of a Medigap insurance policy can vary from state to state. Some states such as Massachusetts, Minnesota, and Wisconsin require Medigap insurance to provide additional coverage than what is defined in the standardized Medigap plans.

Some employers may provide Medigap coverage as a benefit to their retirees. While Medigap offerings have been standardized since 1992, some seniors who had Medigap plans prior to 1992 are still on non-standard plans. Those plans are no longer eligible for new policies. Over the years new laws have brought many changes to Medigap Policies.

For example, marketing for plans E, H, I and J has been stopped as of May 31, 2010. But, if you were already covered by plan E, H, I or J before June 1, 2010, you can keep that plan. Medigap plans M and N took effect on June 1, 2010, bringing the number of offered plans down to ten from twelve.

Congress passed the bill H. R. 2 on April 14, 2015, which will eliminate plans that cover the part B deductible for new Medicare beneficiaries starting Jan. 1st, 2020.

The only two plans that currently cover the part B deductible are plans F and C. Those who enroll onto Medicare after Jan. 1st, 2020 will not be able to purchase plans F or C, however those people who enrolled onto Medicare prior to Jan. 1st, 2020 will still be able to purchase plans F or C. Congress believes eliminating first dollar coverage plans will save Medicare money.

[7]Drug coverage [ edit]Some Medigap policies sold before January 1, 2006 may include prescription drug coverage, but after that date no new Medigap policies could be sold with drug coverage.

This time frame coincides with the introduction of the Medicare Part D benefit. Medicare beneficiaries who enroll in a Standalone Part D plan may not retain the drug coverage portion of their Medigap policy. People with Medigap policies that include drug coverage who enrolled in Medicare Part D by May 15, 2006 had a guaranteed right to switch to another Medigap policy that has no prescription drug coverage.

Beneficiaries choosing to retain a Medigap policy with drug coverage after that date have no such right; in that case the opportunity to switch to a Medigap policy without drug coverage is solely at the discretion of the private insurance company issuing the replacement policy, but the beneficiary may choose to remove drug coverage from their current Medigap policy and retain all other benefits.

[8]The vast majority of Medicare beneficiaries who hold a Medigap policy with drug coverage and then enroll in a Part D Plan after May 15, 2006 will have to pay a late enrollment penalty. The only exception is for the few beneficiaries holding a Medigap policy with a drug benefit that is considered ""creditable coverage"" (i.e.

that it meets four criteria defined by the Centers for Medicare and Medicaid Services); a Medigap policy with prescription drug coverage bought before mid-1992 may pay out as much as or more than a Medicare Part D plan.

Medigap policies sold in Massachusetts, Minnesota, and Wisconsin with prescription coverage may also pay out as much as or more than Part D. Thus individuals who qualify for the Qualified Medicare Beneficiary (QMB) program generally also do not need, and should not pay for, Medicare Supplement Insurance. Some employers offer health insurance coverage to their retirees. Retirees who are covered by such group plans may not need to purchase an individual policy.

While a retiree may choose to switch to an individual plan, this may not be a good choice because group retiree plans usually do not cost anything to the individual and the group coverage is often as good or better than most individual Medigap policies.

Thus the individual should compare his company's policy costs and coverage with the ten Medigap policies. The retiree should also consider the stability of his company. If it is conceivable that the company will falter, that his costs will rise, or that coverage will diminish, the individual may wish to purchase an independent policy.

Remember, however, that if a new policy is purchased the old policy must be dropped. More information at http://cms.gov, http://medicare.gov, http://ssa.gov Enrollment patterns [ edit]In 2006, 18% of Medicare beneficiaries were covered by Original Medicare (Part A and B) supplemented with a standardized Medigap Plan, [1] while another 65% had other coverage through employer-based policies, Medicare Advantage policies, or Medicaid or other public insurance.

[9] Almost a third of Medigap policyholders (31%) live in rural areas; in comparison, roughly a fourth of all Medicare beneficiaries live in rural areas.

[9] Two-thirds of rural Medigap policyholders (66%) report incomes below $30,000. [9]References [ edit]^ a b ""Examining Sources of Coverage Among Medicare Beneficiaries: Supplemental Insurance, Medicare Advantage, and Prescription Drug Coverage,"" Kaiser Family Foundation, August 2008^ ""Medicare Eligibility For Those Turning 65 - Integrity Senior Solutions"". Integrity Senior Solutions. Retrieved 2017-05-16.^ ""Medicare Supplement Insurance"". Medicare Savings Center. Retrieved 21 May 2016.^ ""Making Sense of the Parts and Plans of Medicare - Integrity Senior Solutions"". Integrity Senior Solutions. Retrieved 2017-05-16.^ ""Section 6: Medigap Policies for People with a Disability or ESRD"" (PDF).

Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare. Centers for Medicare & Medicaid Services. 2011. pp. 39–40. Archived from the original (PDF) on September 27, 2011. Retrieved September 20, 2011.^ ""2017 Medicare Supplement Plans"". 2017medicaresupplementplans. Retrieved 22 February 2016.^ ""What Is The Future Of Plan F?"". Blue Wave Insurance Services. Retrieved 2016-03-21.^ ""Prescription Drug Coverage With Medicare Supplements - Expert Medicare.com"". 2016-08-06. Retrieved 2016-08-09.^ a b c Christelle Chen, ""LOW-INCOME & RURAL BENEFICIARIES WITH MEDIGAP COVERAGE, 2006,"" America’s Health Insurance Plans, September 2008See also [ edit]Health insurance in the United States External links Medicare Supplement Overview at Medicare.gov Benefits Grid for the different Medigap plans at Medicare.gov Categories: Medicare and Medicaid (United States) Health insurance in the United States "

. That’s our focus at The DME List. We feel strongly that anyone needing new or slightly used durable medical equipment should have what they need and in the proper size. We also believe that equipment built for long-term use should not go unused with someone who no longer has use for it.

Connect people who need Durable Medical Equipment with people who have it to give.

Connect people who need Durable Medical Equipment with people who have it to give

Are you someone or do you know someone that would like to donate their DME? Are you in need of DME?

Check out our listing and donating buttons on the right and thank you for your support! Examples of Durable Medical Equipment (DME) include: Wheelchairs Transport chairswalkerscrutchestoilet seats3-in-1 Commode Homecare beds Canes Quad-base canes Rollators Bath chairschair liftsuction catheterspressure mattressscootersbathtub grab barsbed railsover-bed tablespedal exercisershydraulic lifts

If you're enrolled in your state's Medicaid program, it will cover the same types of durable medical equipment covered by Medicare Part B. If you have Medicaid but not Medicare, you'll be charged a small co-payment for use of the equipment. If you have both Medicaid and Medicare, Medicaid will pay all of the 20 percent that Medicare doesn't pay, except for a small co-payment. Like Medicare, Medicaid doesn't cover physical modifications to the home. However, some state Medicaid programs have special pilot programs that can help with home modifications.

FAQ: What Kinds of Home Equipment and Modifications Are Covered by Medicare, Medicaid, or the VA?

"FAQ: What Kinds of Home Equipment and Modifications Are Covered by Medicare, Medicaid, or the VA?4 answers | Last updated: Apr 09, 2018A fellow caregiver asked... What kinds of home equipment and modifications are covered by Medicare, Medicaid, or the VA?

Expert Answers Joseph L. Matthews is a Caring.com Expert, an attorney, and the author of Long-Term Care: How to Plan & Pay for It and Social Security, Medicare, & Government Pensions: Get the Most Out of Your Retirement & Medical Benefits . In general, both Medicare and Medicaid cover medical equipment for use at home but don't cover actual physical modifications to the home. The VA, on the other hand, offers some coverage for both: medical equipment through its medical care program, and home modifications through separate grant programs.

Medicare Part BMedicare Part B covers a wide variety of what's called ""durable medical equipment"" for use in a patient's home. Some equipment must be rented, some purchased, and sometimes the patient has a choice. Equipment must be medically necessary and prescribed by a doctor.

Covered equipment can include hospital beds, patient lifts, commode chairs, crutches, walkers, both manual and electric wheelchairs and scooters, oxygen equipment, traction equipment, infusion and suction pumps, nebulizers, blood sugar monitors, home dialysis machines, and many other types of equipment. However, Medicare Part B does not cover equipment that's permanently installed in a patient's home, such as a wheelchair ramp, stair lift, special shower stall or walk-in tub, bars, or railings.

The types of equipment that Medicare Part B covers -- along with information about whether they're to be rented or purchased with Medicare Part B paying most of the bills -- is described in detail in the official online Medicare booklet called Medicare Coverage of Durable Medical Equipment and Other Devices.

Medicare Part B pays 80 percent of the Medicare-approved amount for the rental or purchase of covered equipment. There are special rules, however, for wheelchairs and scooters. It's important to rent or purchase your equipment from what's called a Medicare ""participating supplier,"" who is prohibited by Medicare rules from charging any more than the Medicare-approved amount for the item.

However, a supplier who's enrolled in Medicare but isn't an official ""participating supplier"" may charge more than the amount that Medicare Part B approves for the equipment.

In that case, you'd personally have to pay the difference between the Medicare-approved amount and the amount the supplier actually charges (on top of the 20 percent of the Medicare-approved amount that Medicare Part B doesn't pay).

Medicare's official website provides a geographic directory of equipment suppliers to help you find a Medicare-certified supplier near you who has the specific equipment you need. ""Participating suppliers"" -- the ones who can't charge more than the Medicare-approved amount -- are noted in the directory with a special icon.

Medicare Advantage (Part C) Plans If you have a Medicare Part C Medicare Advantage plan, that plan must cover everything that's included in original Medicare Part B coverage, including durable medical equipment. But sometimes a Medicare Advantage plan covers more, with lower co-payments for medical equipment. To find out whether your plan provides extra coverage or requires different co-payments for medical equipment, contact the plan directly. Medicaid

If you need home modification, check with the Medicaid worker who handles your file and ask if there might be special coverage that can help you. Department of Veterans Affairs (VA)Like Medicare, the Department of Veterans Affairs (VA) program of medical benefits includes coverage of durable medical equipment for use in the home.

In addition, the VA has three programs that offer home-modification grants to certain veterans who have severe service-connected disabilities. These are: Specially Adapted Housing (SAH) grants. An SAH grant is to help modify a home to make it wheelchair accessible or otherwise ""barrier free"" for certain veterans whose severe service-connected disabilities make it impossible for them to live independently without such modifications.

An SAH grant can be as much as $63,780. Special Home Adaptation (SHA) grants. An SHA grant helps pay to modify a home -- the veteran's or a family member's where the veteran lives -- to meet the needs of certain disabled veterans who need assistance with mobility around the house.

An SHA grant can be as much as $12,756. Home Improvement and Structural Alteration (HISA) grants.

A HISA grant provides funds for home improvements necessary for a disabled veteran to have access around the house and for essential lavatory and sanitary facilities. A HISA grant is available to a disabled veteran even if the disability isn't service-connected. HISA grants are up to $4,100 for a veteran whose disability is service-connected and up to $1,200 for a veteran whose disability isn't service-connected. For more detailed information on these home modification grant programs and how to apply for them, see Home Modification for Veterans with a Service-Connected Disability. Community Answers Chris moore answered... Excellent information on paying for medical equipment and home modifications.

I would add that the limits for HISA grants have been raised to $6,800 for service connected disabilities and $2,000 for non service connected disabilities. Phil davis answered... With the increase in the HISA grant, a client can typically receive a bathroom remodel to meet their needs without any out-of-pocket money. Its like getting a bathroom remodel FREE. Charley52 answered... Sent a note earlier hope you get it.

Thank you! Charley52Add an answer READ THESE NEXT: V. A. Medical Benefits Medicaid Coverage of Nursing Home Care in 2018FAQ: Can Medicaid Coverage Be Retroactive? Assisted Living Costs Near You Compare pictures, pricing, options. Get Information "

Can I expect my insurance or Medicaid to cover the CPAP (continuous positive airway pressure) machine? Yes, most insurance policies cover CPAP. CPAP is considered to be durable medical equipment, and you can call your insurer to find out the specifics of your coverage. Deductibles and copayments for medical equipment may be different than what you pay for office visits or prescriptions. Medicaid does cover CPAP equipment, but it will need authorization.

CPAP 101: Expert Tips For Getting Started with Continuous Positive Airway Pressure (CPAP) Machines

Home / Ask The Expert / CPAP 101: Expert Tips For Getting Started with Continuous Positive Airway Pressure (CPAP) Machines CPAP 101: Expert Tips For Getting Started with Continuous Positive Airway Pressure (CPAP) Machines Dr. Helene A. Emsellem I’ve just been diagnosed with sleep apnea.

Supplies are covered separately, and the amount of coverage varies by state. Deductibles and copayments may apply depending on whether or not you have a secondary insurance. What kind of mask should I get for my CPAP? Nasal pillow systems, nasal masks and full face masks are available in all sizes, shapes and styles from a variety of vendors.

They are all effective. The delivery system selection is very personal. On the night of a CPAP titration study (similar to the sleep study), we encourage patients to try on a variety of different types, guided by our experienced technologists.

We ask patients to choose a first and second choice and to let us know if they are uncomfortable during the night so they can make a change. We find that even with maximal attention to mask/pillow fit prior to the first night, about 10-15% of the time patients may have an issue with irritation, air leaks or discomfort and may need to make a change over the first few weeks to optimize adaptation.

What should I do if my nose is runny or I have a dry mouth after using the CPAP? Humidification of the air in your CPAP system can be extremely helpful in managing both dry mouth as well as a runny nose. Most current CPAP setups include humidification chambers. Studies have shown improved comfort and compliance when the humidity is used.

The humidity setting may need to be adjusted, with a higher setting required in cold climates during the heating season. A persistently runny nose can be a problem and sometimes this1 2 3 4 ›

CPT codes identify medical procedures and HCPCS are codes to identify various different medical supplies such as medications (J codes) and DME (durable medical equipment), etc …What

5 thoroughly explain the differences between icd9 cpt and hcpcs coding?

"Answers.com ® Wiki Answers ® Categories Business & Finance Insurance Medical Insurance 5 thoroughly explain the differences between icd9 cpt and hcpcs coding? Flag5 thoroughly explain the differences between icd9 cpt and hcpcs coding? Answer by Kguidry39 Confidence votes 73International Classification of Diseases (ICD-9) coding is a statistical classification system that arranges diseases and injuries into groups according to established criteria.

Most ICD-9 codes are numeric and consist of three, four or five numbers and a description. Example: An ICD-9 code for a broken arm is fractured radius, 813.81. In addition, injuries are also coded according to their location on the body. So, the code for the broken arm would indicate whether it was the left, right or bilateral (both) arms.

In addition, an injury site may be listed if necessary. Site locations apply to injuries to the fingers, teeth and toes. CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services.

They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer.

Since everyone uses the same codes to mean the same thing, they ensure uniformity. HCPCS Codes, Healthcare Common Procedure Coding System numbers, are the codes used by Medicare and monitored by CMS, the Centers for Medicare and Medicaid Services. They are based on the CPT Codes (Current Procedural Technology codes) developed by the American Medical Association. HCPCS Codes are numbers assigned to every task and service a medical practitioner may provide to a Medicare patient including medical, surgical and diagnostic services.

Since everyone uses the same codes to mean the same thing, they ensure uniformity. For example, no matter what doctor a Medicare patient visits for an allergy injection (code 95115) that doctor will be paid by Medicare the same amount another doctor in that same geographic region would be.2 people found this useful Was this answer useful?

Yes Somewhat No What HCPCS CPT code is used for a wheelchair evaluation in the home? What is a HCPCS code?

. HCPCS (often pronounced Ahickpicks@) stands for the Healthcare Common Procedure Coding System. It was established in 1978 as a way to standardize iden …Difference between hcpcs and cpt codes? CPT codes are used to describe medical, surgical, and diagnosticservices and are used among physicians, coders, patients, andfinancial departments.

HCPCS codes are the same ex …What field is the cpt or hcpcs code inserted in?24D on he HCFA-1500 form (08/05)What is the HCPCS or CPT Code for .9 percent sodium chloride irrigation solution 1000ml?

A4217 sterile water saline Joyce Galloway Parker 21,774 Contributions Majored in psychology, studied domestic violence, spousal and child abuse, have a lifetime of observing people, their actions and reactions.

What is difference between ICD9 and ICD10? ICD9 is International Classification of Diseases, 9th edition; ICD10 is International Classification of Diseases, 10th edition. These are diagnosis codes, used international …Sdwonz 1 Contribution What is the difference between an ICD9 code and a CPT code? ICD9 code is the diagnosis code and a CPT is the procedure code Karma41 1 Contribution Which icd9 code is use with cpt code 90862?

It depends on the reason the patient is receiving the treatment, for example bipolar, personality disorder ect. There is not one specific code that is to be used with 90862, i …Are there duplicate codes between icd9 and icd10 but have different meanings?yes. there are approximately 38 codes that are used in ICD-9 and reused in icd-10 but with very different meanings What is the difference between the word thoroughly and throughly? ""Throughly"" is the archaic form. What is the difference between hcpcs and cpt codes?

organizations are responsible for updating cpt codes and hcpcs level ii codes? AHIMA, and AMA (American Medical Association)XBKforever 31 Contributions What is the difference between cpt code?

And hpcps? CPT codes identify medical procedures and HCPCS are codes to identify various different medical supplies such as medications (J codes) and DME (durable medical equi …Answered In Medical Insurance Are cpt codes and hcpcs codes the same?yes Answered In The Difference Between What is the difference between 99203 and 99213 cpt codes?99203 is an initial comprehensive Examination 99213 is a comparative or reevaluation, less comprehensive, in that it re-evaluates the previous positives unless there is new in …Answered In Uncategorized Does the HCPCS have its own listing of modifiers and how do they differ from the CPT modifiers?yes it does Answered In The Difference Between What is the difference between CPT codes 54150 and 54160?54150 is surgical circumcision of males under the age of 28 days ofage.

54151 is surgical circumcision of males older than 28 days of age Answered In Wheelchairs What is the HCPCS CPT code for a wheelchair ramp?95925 "

e A deductible, which is a set amount you pay each year before Part B starts paying for any of your care Twenty percent of the Medicare-approved amount for some types of care. These are doctor's appointments, physical therapy, diabetes supplies, durable medical equipment like commode chairs, wheelchairs, and other c

What Does Medicare Cover?

If you’re eligible for Medicare and ready to explore your options, the first step is to get to know its four parts. Each part represents a different kind of coverage. Part AAlso called hospital insurance, Medicare Part A covers the cost if you are admitted to a hospital, skilled nursing facility, or hospice.

It also covers some home health services. Most people are enrolled automatically in Part A when they reach age 65. With Part A, you'll pay: A deductible each year. This is how much you have to spend before Medicare starts to pay its part. Coinsurance. This is the part of the costs for hospital care you may be required to pay after you've met your deductible.

If you or your spouse receives Social Security benefits, you don't have to pay a monthly fee to have Part A and will be automatically enrolled.

If you or your spouse doesn't receive Social Security benefits, either because you are still working or because you don’t qualify, you will need to join through your local Social Security office. You will have to pay a monthly fee to have Part A if you are not eligible for Social Security benefits.

Part BAlso called medical insurance, Part B covers outpatient care. For instance, it pays for your visits to a doctor’s office, tests, and preventive care like cancer tests and vaccines.

Part B also covers some medical supplies, like blood sugar test strips, therapeutic shoes, and more. It’s common for people to be automatically enrolled in Part B, too. For Medicare Part B, you pay: A monthly fe

are. You have to meet your deductible first and then pay 20% of the services you receive. If you see a doctor who has not agreed to accept Medicare-approved amounts, you will pay more -- possibly up to the full cost -- for a doctor's visit and care.© 2017 Web MD, LLC. All rights reserved.1 2

010Is it possible to start a homebase business in Durable Medical Equipment, (DME), strictly selling power wheelchairs.kathlyn Jadrosich said on January 11, 2010I need advice on starting a medical supply business out of the country.

Starting a Medical Equipment Business

"Starting a Medical Equipment Business245 comments 36 expert advice 126,151 views Health is always given a high priority in all respects - Current generation is conscious on having a periodic checkup and maintaining sound health. This awareness gives an upper hand to medical business and hence the hospital equipment supply business.

Facebook Tweet Google Share Linked In Pinterest Email A medical equipment business is a good venture to invest on particularly because of the booming healthcare industry. Getting into a business that supplies home medical equipment and hospital medical equipment can be very profitable. It is however essential that you equip yourself with the necessary know- how in marketing medical equipment supply for you to become competitive in medical equipment sales.

Here are some things that you have to remember when starting a medical equipment business: Choose a good location where people can easily buy medical equipment from you The type of merchandise that you are selling is the ones that people will actually look for after a visit from the hospital or from their doctor.

It is therefore a great idea of you choose a location for your medical equipment store that is near, visible and accessible from healthcare establishments like hospitals and clinics.

Being able to sell medical equipment supply from these areas will allow people to easily see you when they are looking for home medical equipment or hospital medical equipment. People will also find it easier and hassle-free to buy their medical equipment supply from a medical equipment store that is near them or is very accessible.

Get the best deals from medical equipment manufacturers In order for you to do well in the medical equipment business, it is a must that you price your goods competitively.

This requires that you get the best deals from medical equipment manufacturers where you will be getting the supplies that you will sell in your medical equipment store. You can do this by contacting medical equipment manufacturers and telling them about your business. Most medical equipment manufacturers can provide special prices for medical equipment stores. Get quotes and ask possibility of discount for bulk orders.

Similar Articles How to Start a Medical and Dental Clinic Cleaning Business? Tips to Sell Medical Supplies Know what medical equipment sells best If you have limited capital and you cannot afford to make every medical supply available for your clients, it is best that you know what particular medical equipment sells like pancakes and which ones seldom sell.

You may decide not to purchase medical supplies that do not sell well but you also have the option to offer your clients an order system when they need to purchase hard- to-find items. If you cannot provide every medical equipment brand for your medical equipment store, get your supplies from reputable and established medical equipment manufacturers because many people still prefer to buy medical equipment made by reputable manufacturers.

Recommended Articles Tips to Become a Medical Transcriptionist In learning how to become a medical transcriptionist, you must know the requirements of the job such as a completed medical transcription training program.

Also, you must know other essential factors that come with this course like the certification and how the salaries are determine. Starting a Hospital Transportation Business Do you have interest in healthcare business? Are you planning to start a medical transportation business?

If you are, this is a great way to earn good profits.<< Starting a Septic Tank Business Starting a Cleaning Business >>245 Commentsalfonso arredondo said on July 30, 2009excellent advice. thanksedithgriffiths said on August 12, 2009i need to know how to start a medical rehabilitation center step by step.

Yusuf Hassanali said on August 16, 2009I am Pharmacist and I am trying to start a medical supply store and I am looking for information and resources on how to start up medical supply business. Please help? ARON ARANBAYEV said on August 18, 2009HOW DO I OPEN A MEDICAL SUPPLY STOREprojeet said on August 23, 2009How do I start medical equipment business from home?carol Graham said on October 25, 2009I need info how to start a medical equipment business.

i'm in the maryland area the license etc. Deanna Myers beginner adviser said on November 7, 2009First, let me post an introductory message. I have been a consultant in the medical equipment industry for 12 years. Navigating the regulatory mine filed can be overwhelming.

My consulting firm offers start-up assistance packages with step by step guidance. I will attempt to offer some helpful suggestions for this journey. You are welcome to contact me directly at deanna.myers@att.net Deanna Myers Medical Equipment Consultant deanna.myers@att.net Deanna Myers beginner adviser said on November 7, 2009@projeet - starting a medical equipment business as a home based business will be difficult. Most medical equipment is reimbursable through health insurance coverage and most home medical equipment ""patients"" that is the end-user have medicare coverage.

Medicare, state Medicaid and most of your health insurance carriers DO NOT issue provider numbers or recognize providers that are home based businesses.

Wish I had better news. Understand though if you are selling equipment for cash - go for the home based business - but understand that since you cannot offer the option to have insurance reimburse their cost, you will have a difficult times getting sales.

Deanna Myers Medical Equipment Consultant deanna.myers@att.net Deanna Myers beginner adviser said on November 7, 2009@edithgriffiths - can you provide more detail on this start up? A rehab medical equipment company is definitely a niche market that few undertake, but there are some specific regulations you have to abide by.

Deanna Myers Medical Equipment Consultant deanna.myers@att.net Deanna Myers beginner adviser said on November 7, 2009@Yusuf Hassanali - I have a number of clients that are pharmacy/hme (home medical equipment companies. You are actually in a unique position! The thing I would tell you is that - you cannot operate the hme side like you operate the pharmacy side. The billing for HME is NOT AT ALL like the billing for pharmacies! You need to decide exactly what you want the HME ""division"" to bring to your pharmacy.

Often I am asked to go in and ""fix"" a struggling HME ""division"" because Pharmacy owners know the huge potential of this but do not know how to achieve the end result.

From marketing to delivery. I would love to discuss this with you in more detail. Deanna Myers Medical Equipment Consultant deanna.myers@att.net Deanna Myers beginner adviser said on November 7, 2009Now for those of you that are simply wanting to know where to begin...there are a number of land mines! First - do your due diligence and determine exactly what products you want to offer and their profit margins.

Some products require more work and you have to keep that in mind - it slims your profit margins. Some product lines pay on a capped rental (kind of like rent to own) over a period of time and you are responsible for the maintenance as long as it is considered a rental.

Deanna Myers Medical Equipment Consultant deanna.myers@att.net Deanna Myers beginner adviser said on November 7, 2009Second - you must determine which payer sources you will be a provider for. Most (almost all) medical equipment companies are enrolled with Medicare and Medicaid and have private insurance contracts. Now, to obtain a provider number with Medcare you must meet all 26 supplier standards. The biggest, most labor intensive of these being - you must be accredited. There are a number of accrediting bodies but there is a minimum $2,500.00 cost and that is a REALLY low number.

You must choose wisely! Most Medicaids are requiring this for new suppliers or will be shortly as well. Most private insurance carriers are requiring this to be considered in-network. Deanna Myers Medical Equipment Consultant deanna.myers@att.net Deanna Myers beginner adviser said on November 7, 2009Third - know how to get reimbursed. There are a lot of different softwares out there. Doctor billing software is not conducive to medical equipment billing! Some software is expensive! Some are web-based. I have a strong opinion about the web-based programs.

But I will respect what they do and offer and not offer that opinion here. There are billing services that can do your billing for you if you do not want to purchase software right away. Know what they are doing! Make sure what they are reporting to you is enough. Remember, they work for you.

Be careful who you choose. Deanna Myers Medical Equipment Consultant deanna.myers@att.net Deanna Myers beginner adviser said on November 7, 2009Last - Know your payer sources rules! You must know how to be compliant. There are specific guidelines you must follow. Do not allow someone to tell you how it is done. Make them SHOW you in writing. Don't hire someone that can ""run"" your company and/or billing department unless you know that they are doing things the compliant way!

Do not hire a consultant that just says ""do it this way"" and cannot SHOW you why! You - the owner - are ultimately responsible for what goes on in the company, so knowing the compliance and regulatory part of this business is imperative! Hope this helps! If you have any further questions or would like further assistance, again you are welcomed to email me at deanna.myers@att.net Deanna Myers Medical Equipment Consultant deanna.myers@att.net Javier Juarez said on November 19, 2009Harlingen, Tx.

Ms. Myers how can I get a hold of your start up assistance packages with step by step guidance? Please help. Javier Deanna Myers beginner adviser said on November 28, 2009Javier Juarez - You may email me to get started. My email address is deanna.myers@att.net. Deanna Myers Medical Equipment Consultant deanna.myers@att.netlewis said on December 3, 2009I need step by step info on how to start a medical equipment business.

Please contact me ASAP. Thankx Mitch Tucker said on December 7, 2009Edison, NJ, USA I need to start a Medical Equipment Business. I need guidance from scratch to finish. How can you guide me. Regards, Mitch Mike said on January 3, 2010Hi Deanna, I am thinking of buying existing DME business with Medical and Medicare provider number.

Currently I am discussing with couple of seller in California. They will take joint liability until I get my provider number. Can you please guide me further in this regard. Especially with things to watch for during the buying business process. Thank You, manoj Deanna Myers beginner adviser said on January 4, 2010Mike...please contact me directly. deanna.myers@att.net for further information Deanna Myers Medical Equipment Consultant deanna.myers@att.netanthony said on January 8, 2010Hannover, MD, USA Deanna, I need help in starting up a home base medical supply business that specialize in wound care. Can you please help me get started. Allen Parson said on January 10, 2

010Is it possible to start a homebase business in Durable Medical Equipment, (DME), strictly selling power wheelchairs.kathlyn Jadrosich said on January 11, 2010I need advice on starting a medical supply business out of the country.

Do not need any info on medicare or medicaid or any other insurances. I just need general information on how to go about it. I am an occupational therapist from the WEST INDIES. THANKSAlex Y. said on January 20, 2010Hi Deanna, thank you for all your inputs. What is your training includes? Is your manual adapted to the California’s laws? How much do you charge for your service?

Thank you.tammy said on February 4, 2010hi looking into starting my own medical supply business do not know what kind of equipment i can or cant sell to not have to go through the process of having to join the state board of medicine? where can i find this information and is it a hard process to go through if i had to or wanted to?

thank you input appreciatednazrul said on February 6, 2010Bronx, NY, USA. Dear Deanna Myers: I been reading your comment for a few days. I also been talking to one of the medical supplies store owner. I am asking him to tell me how can I start ""the medical supplies store""?. He is reluctant to give me any kinds information. Please if you could help me I would grateful to you.

In the mean time, I must tell you that I have been running my own discount/ 99 cent type business last 10 years. First 2/3 years I was doing well but last 5/6 years it went down so bad that now unable to pay my store rent.

I am hurting badly, and therefore, looking to do something that might little rewarding. Also I don't know if this would help my previous experience, please let me know how can I start the Medical supplies business?

Thank you for your help and advice. Nazrulrupa said on February 6, 2010can u please give me a clear idea of the fuctionalities of a medical agency?

and what actually a medical agency is? John said on February 15, 2010Deanna Myers, Please let me know how can I get more information about your service regarding DME start up. Thankstumi said on February 23, 2010HI, i'm a radiographer by profession with no business background whatsoever, i'm looking to start a medical supply company, i've only gone as far as getting a CK1 AND A PROFILE, CAN u kindly assist me with the step by step from here, i'm in KZN, MARGATE.

THANXKory said on March 13, 2010Hello Deanna - Thank you for all your help! I have sent you a email directly and look forward to hearing from you soon.

It is great to find an expert willing to help. Its hard finding info on DME Start Up. Thanks again - KDJJill said on March 16, 2010I'm interested in learning how to start a DME company and need step-by-step information on start-up.

Thank you. Jill West Chester, PAAdam A. said on March 21, 2010I own a DME company for around 10 years. It takes around 6 months to get accredited and get a new medicare number to start a DME company from scratch and begin billing Medicare.

The Center for Medicare Services (CMS) authorizes any of 11 companies to use to get accredited by Medicare. They are listed below. If you are looking to break into DME sales. We may have openings for reps in various parts of the country.

We specialize in wound care products. You may email me at medsales@mac.com. -Adam Kory said on March 31, 2010Thanks Adam, My Wife and I are both in the Med.

field here in CA and have not gotten a replay from Deanna. Do you or do you know of a service to hire to help with the process of a new DME Start up? Thanks again - KDJlisa said on April 24, 2010For non-medicare billing such as PPO and HMO plans is a prescription required for facilities billing diabetic supplies that are legend items and be purchased over the counter?

California locationsandeep sharma said on April 27, 2010To dear Team, I want to start my own Business in medical line like selling and supply chain.

So plz guide me that where should i have to start my business, should i contact to any organization of branch for participate, plz guide me. Thank you Lisa said on May 4, 2010I am in the state of NC and I would like to know how do I start a Medical Supply Business from start to finish in the state of NC.

I look forward to any feedback or information, thanks in advance.shanta subdhan said on May 5, 2010Hi, I am working at a Dr's office presently and we are ordering a lot of medical equipment for our patients. I would like to know if I could be that supplier instead. This would then be a home-based business, but I can put a sign outside of my house with a company name, and as a medical supplier.

Can I become accredited and get reimbursed from the insurance co. as well. If so, how can I get started, please help me, thank you.

Mustafa said on May 6, 2010Hi, i own a medical transportation company in MN, and i was told that i can bill for medical supply, i want to know what kind of steps do i need to take from here,Rochelle Gray said on May 21, 2010My business location is in michigan, I am looking for information on how to start a medical supply delivery service. Please help. Nyree Letterlough said on June 1, 2010I would like some information on starting a medical equipment repair business.kathy said on June 18, 2010Hi Team: I am a chiropractor in CA and want to implement a DME business with my practice.

Please give me the advice of the steps I should do. how to look for the supplier with meet medicare for reimbursement. Do I have to be a insurances contract provider for reimbursement. Thank a lot. Kathy Eli said on June 20, 2010Hello: My business is located in Katy Tx.

I just set up the office and applied for license from department of health and human services. How do i enroll in the Medicare and medicaid networks and the Doctors networks?

information on how to start will be highly appreciated.sunny said on June 21, 2010My office is located in Houston as a DME supplier and i will like to know if i need to apply for NPI number through CMS in order to enroll in Medicare network and accreditation. Thanks . Sunny.pat said on July 1, 2010@ shanta subdhan , could you contact me @pt.promotionals@comcast.net I have info on helping you selling med equipment.sergio del angel said on July 8, 2010mission, texas, usa.

i want to know how to open a DME EQUIPMENT BUSINESS can you please helpnazreen khan said on July 10, 2010hi, I am a chiropractor in Ohio and I would like to inquire about your services and want to open a DME business.

Can you contact me. I need help on opening this type of business. I have marketing experience and a very successful chiropractic office and am looking to open a home based or warehouse based DME company.bj said on July 12, 2010Hi, I want to sell medical equipment in china from a home base business, what are the restrictions.

Thanks Gwen Daniels said on July 14, 2010Hello, I am a RN in Georgia and i'm very interested in starting a DME home based business.

Please help. Chris said on July 23, 2010I am starting a lift company in Florida, I probably will handle two lines of products. I came from that industry and have many connections, anyone interested in helping out, please get in touch with me.

I have a DME number through a shared associated but we plan on incorporating in Florida.manish said on July 24, 2010hi, this is manish, i want to start business of distributionship of medical equipment in kalyan, maharashtra, indiabenjie said on July 30, 2010hi my name is benjie i would like to start a DME business in florida can any one help me home base to start out withbenjie said on July 31, 2010I am in medical field for a long time and would like to start a medical equipment/machine business in orlando florida Rosa Romo said on August 6, 2010Located in Orange County California and Austin Texas.

I would like to start the process of investigating the medical supply and equipment business. I do not know where to start or what questions to ask, I only know that the economic trends show the medical field as a viable way to go for.

Please contact me regarding your services. Thank You. Mayla said on August 12, 2010Hi, I am an Registered Nurse and need advice on starting a medical supply business out of the country. I am interested to find out where to buy the medical supplies & what the rules & regulations are shipping them to overseas. Your feedback is greatly appreciated. Susan Helgren said on August 16, 2010need advice on beginning a medical supplier in Austin, Texas MARIO MATUTE said on August 18, 2010I NEED HELP.

I AM IN THE PROCESS OF OPENING UP A COMMUNITY CLINIC (BREAST CANCER DIAGNOSIS) I HAVE THE SPACE DONATED BY THE LIONS CLUB, AND THE STAFF WILL BE PAID BY DOCTORS WITHOUT BORDERS.

I NEED A MAMMOGRAPHY (USED IS OK) AND ANY OTHER MEDICAL EQUIPMENT THAT YOU GUYS CAN DONATE. I SINCERELY APPRECIATE YOUR HELP.

BLESSINGS TO ALL, MARIO MATUTE www.elsalvadorusahealthcare.org 818 395 7787webo said on September 3, 2010Hello I am in medical transportation industry and want to change it to medical supplies rental or to become Medical equipment supplier so please tell what you think. god Bless Fritz said on September 3, 2010My name is Fritz, I am contemplating about the medical supply business.

I have a friend who has been very successful with his company and he just obtained his medicare license after two years of service. My question is, how can I get started without a Medicare license and with many insurance companies requiring contract for reimbursement? Also, are there many companies who reimburse to out of network medical supply business? Mhizaki said on September 15, 2010can you tell me how much does it cost for all medical equipment that an hospital needs?

Victor Ilegbodu said on September 24, 2010Please I need your guidance to start a home medical care equipment supply and services.

I am a public health administrator with no business background. I live in Chicago, Illinos USA. What are the basic things I need to be able to start a home medical care equipment supply and services. I want to be able to supply medical care supply for both chronic and acute illness, including rehab equipment and services.

I can satisfy licensure requirements in my state to start a medical care supply and services. I have the physical space to use for the business, but lack the knowledge on how to go about obtaining the products and marketing them.

Please help me! Thanks. Sincerely, Victor Ilegbodudeveshpandey said on September 28, 2010hi i m a bpharm student & i m interested in my own medicine hospital supply business in india so i need information about primary investment & business plan & marketing strategy. Please help me!najam said on September 29, 2010i m Thinking to start dme business can i open a company with my home address and then look for commercial space?

and what other steps or thing should i get ready? Rafath said on October 6, 2010Hi, I want to start medical equipment supply business, currently in Chicago, IL. Please let me know details.. Rafath Jullia said on October 6, 2010Mobile, AL. I am thinking about starting a home-based medical equip business selling supplies for seniors, nursing homes, athletic trainers, midwives and doulas.

Would you please tell me how to get this up and going. I have no knowledge I just learned this is a lucrative business and I want to start my own. PLEASE HELPFozia said on October 17, 2010I want to start a medical equipment or supply business in Orlando, Florida.

I have an office space I use for accounting services. I need advise on how to get started. Thanks. Bernie said on October 19, 2010Thinking of starting a DME business in California. Any advice?qammar said on November 25, 2010hello, I am Qammar and i want to start a medical equipment supply business in Pakistan & other country if anybody want to medical related or some thing els plz contact me and some one advise me plz contact me on my E-mail or my cell number 092-300-5312347Nathan Jacobi beginner adviser said on December 1, 2010Los Angeles, California.

I am a principal for Prodigy Medical a manufacturer and distributor of medical supplies throughout the U. S. I noticed the post and if I can be of any help feel free to reach out to me direct. My company specializes in helping those interested in starting a DME company as a distributor or wholesaler and I would be more then happy to assist.

You can view our products at www.prodigymedical.com or email me at nathan@prodigymedical.com Nathan@prodigymedical.com Alan Myers said on December 14, 2010For all of you who are wanting to email Deanna Myers directly with questions, please email her @ deanna.myers@att.net Shelley Walton said on December 28, 2010Deanna,i must start out by saying wow i am Lucky!

To come across This Web -site by Pure Chance! Jan. second day after Newyears I have been offered a partime job at a small ,but a Rep. Established, med store in CL LK, IL. The owner sent me home a couple weeks ago with a Med. Supply Magazine, also I've read his nice Web-site.

I can not seem to get interested in learning the book, but Would REALLY like myself to although not much money, i thought if i could sell, i could get more Hours=$ so I'd really like a copy of Your; Of Your Teaching Manuel, book; Please e-mail soon give all info i would need for ordering, shipping, money$$$ Thank you so much looking forward from hearing from you Shelley Walton=sscally1776@hotmail.com Thanks again for People like You!!

!Tajammal Bukhari said on January 1, 2011I want to start the sales of medical instruments to overseas could you please give me your views Angelika said on January 6, 2011NJ Area.

Hi- I have a DME provider's number. But I don't have any business. I work in an area where a lot of Senior Citizens live. How can I get more business from Hospitals and Doctors offices. Please advise. Thanks Joe Kadic said on January 9, 2011Hello, I'm a pharmacist who is planning on opening a pharmacy.

Also, I'd like to offer DME services for my customers to assist them with their health care needs.

Sac, CA. Sneha Hotchandani said on January 27, 2011hi i would like to know regarding the various licenses required for starting a hospital in india. i m assisting in the hospital projects in a pvt. company who is into the business of construction. we are going to build hospitals. so i would like to know the requirements to be fulfilled and the licenses to be obtained for the above mentioned purpose.

i'm from Pune, maharashtra, India. Jenny said on March 5, 2011I want to start a medical equipment or supply business in Philadelphia of PA I have an office space. can you help to getting start? James expert adviser said on March 6, 2011@Jenny, what you exactly need from me?

Do you need help on registering your business or help for finding the manufacturers. Jestin James Startup Biz Hub - Senior Advisor (Staff)latanya lewis said on April 1, 2011hi, i would like to start a medical supply business and i want to sell wound care, diabetes supply walkers, i live in chicago i dont know where to start can u give me the information on how to get started and what i need to open a medical supply Juliette said on April 6, 2011Hi, I was interested in starting up my own DME Company and just dont know or have the resources to do so.

I am already a medical biller and have my own company. I live in Miami, FL and already have a location for the DME in mind. All I need is some guidance. RON said on April 13, 2011CAN YOU PLEASE TELL ME WHICH ACCREDITATION IN AFFORDABLE PLEASE.

THANKSsandy said on April 19, 2011business location georgia i'm interested in opening in a DME store and need help from start to finish need to know where to contact in ref to license billing medicaid/medicare just everything thanks look forward to hearing from you Roni beginner adviser said on April 20, 2011Ron, there are many different agencies and based on what you are providing will determine the best one for you.

I can help you, I would just need more information from you. Sandy, I can assist you with this process.roniparc@gmail.comsandy said on April 21, 2011business location atlanta ga interested in starting a DME store need help from start to finish who would i get in touch with in ref to billing medicare/medicaid companies to work with in getting started thank you and i look forward hearing from you Roni beginner adviser said on April 21, 2011Latanya, do you already have a location set up?roniparc@gmail.com Joy said on April 28, 2011I have a home care agency in Georgia, and am interested in becoming a DME supplier.

Does anyone know of any manufacturers that I could begin talking to in terms of supply. Thanks!Ameda said on April 30, 2011Hi, I needed information on starting a medical supply company from start to finish.

I know this is a profitable business because I have a father who is a nursing home and all the items we had to purchase were expensive. I also work for scientific distributor that sells various items including some medical supplies and i recently saw them meeting with a minority small business owner and knew right then they would not be wasting time with him if they weren't going to be making a huge profit from him.

i want to open the supply company in gwinnett county about 30minutes outside of atlanta ga.sabri said on May 8, 2011small business for transportation medicare how i start with patient Victoria said on May 13, 2011Louisiana--HI I'm interested in being a medical supplier for hospice companies.

I will not bill any insurance companies. That will be their responsibility! However, I need to know how to proceed with the business from start to end.

Is it the same as a regular DME start up business or something entirely different? Please assist me.gin beginner adviser said on May 26, 2011New Jersey, Hi I have been in the DME industry for over 25 years and it is getting harder and harder with the competition and all the requirements that are needed to be met through medicare, no fault , workers compensation etc...

If you have the stomach to wait endlessly for payment then go ahead and start your businesses, but be warned it's not all roses on the other side!

you may contact me if you have a question. For Angelika contact me if you are interested in selling equipment. Kumar Rambhatla said on May 31, 2011Hi Deanna, I am thinking of buying existing DME business with Medical and Medicare provider number in Glendora California. Currently I am discussing with couple of sellers in California. They will take joint liability until I get my provider number.

Can you please guide me further in this regard. Especially with things to watch for during the buying business process which is a Stock Sale & what is a Stock Sale & what to look for. Thank You, Kumar Deanna Myers beginner adviser said on June 6, 2011@Kumar, there are a number of things to look for. You must be careful in how the buyout takes place. One thing you have to know is how accreditation and Medicare will look at this transaction.

You may still be required to get new provider numbers and that could first jeopardize your status with Medicaid. There is a balance to the process. My first ""warning"" is that you can ultimately be held responsible for past if this isn't set up correctly.

If the current owners have not been compliant; you cannot separate from that through some buyout processes. So, do your homework and audit charts for compliance. Next, regarding the seller; does there reputation proceed them or follow them. Cleaning up a mess is difficult at best in this industry and the work to turn around bad referral relations is hard given the competition. I, also, caution you in that a patient populous is great, but you have to look at actually paying customers.

You may email me directly to discuss the specifics of what to look for. I do offer evaluation services. My email is deanna.myers@att.net Deanna Myers Medical Equipment Consultant deanna.myers@att.netoratile seitshiro said on June 11, 2011country: Botswana (Southern Africa) am a young business person and my country has been having a shortage of medical supplies/pills/medicine for many years and basically this point has pushed me to want to start a company that supplies the government and private entities medicine..please generally help.this is an opportunity.it is time someone stepped in and am willing to go that extra mile Steve P. said on June 20, 2011Westchester County, Bronx County, NY.

I am very eager to obtain all the information, strategies, and procedures necessary to open a DME company in the bronx, and westchester area.

I have capital to invest, and want to know how to get a medicare provider #Shana Cohen Finkelstein beginner adviser said on June 23, 2011I am an R. N. director of patient services for a Home Health care Co in NYC,NY. I am constantly giving business to multiple DME vendors and realized that with my contacts that I have accumulated over 20+ years in the industry I am ready to take that leap.

I have an interested partner who is a physical therapist who has many contacts as well. Let me know how we can avail ourselves to your consulting services. Marlon said on July 5, 2011I would like to start the business in san Francisco bay area possibly expanding or moving to LA area.

What would be your input on this and what wouldn't cost me to consult the business start up. Would like to provide rehab set up equipment for home and hospice equipment and oxygen. Thanks. Carie said on July 12, 2011I'm in Orange Co. California..start-up..how long to grow business?

Senior/diabetes supplies niche business Norman said on July 17, 2011Started a medical supply business in february and having problems finding suitable suppliers that work with new businesses.

Need help in locating suppliers/wholesalers with decent pricing. Nathan Jacobi beginner adviser said on July 20, 2011To all those who are interested in starting a DME business whether it is wholesale, retail or e-commerce, feel free to reach out to me. Our company has been manufacturing and distributing medical equipment nationwide for over 5 years, offering competitive pricing and sales strategies.

If you need help or have questions, I am more then happy to give you my insight and assistance in any way possible. Regards, Nathan Jacobi, Nathan@prodigymedical.com Nathan@prodigymedical.comneil jones said on August 5, 2011I live in te Chicagao IL. area and looking to start a med. equipment rental business. What amount of upfront moe is needed and how profitable is this kind of business? I read some of the other comments and they mentioned a provider number how can I get one.k shankar said on August 10, 2011i would like to start marketing medical equipment consumables as there is lot of potential in India as there are lot of hospital project coming up . i would like have the addresses for various companies in the Field of sterilization,radiology and surgery Andrea said on August 16, 2011I work for an Urgent Care facility in State College Pennsylvania. My employer would like to expand into durable medical equipment, and has assigned me the task. Can anybody advise me exactly where to start? (0) 1 2Comment ( All the above fields are required.) "

CMS is responsible for the operation of the Medicare program and for selecting Medicare administrative contractors (MACs) to process Medicare fee-for-service Part A, Part B, and durable medicine equipment (DME) claims.

HCM #2

"212 terms cmagliulo HCM #2Learn Flashcards Write Spell Test Match Gravity Advertisement Upgrade to remove ads Like this study set? Create a free account to save it. Create a free account Maybe later Sort Single payer plan -centralized health care system adopted by some western nations (canada, GB) and FUNDED BY TAXES -govt. pays for each resident's health care, which is considered a basic social servicesocialized medicine -a type of single-payer system in which the govt owns and operates healthcare facilities and providers (e.g.

physicians) receive SALARIES -the VA healthcare program is a form of socialized medicine Universal health insurance -the goal of providing every individual with access to health coverage, regardless of the system implemented to achieve that goal Group Health insurance -traditional coverage subsidized by employers and other organizations (labor unions, rural and consumer health cooperatives) whereby part or all of premium costs are paid for and/or discounted group rates are offered to eligible individuals%'s of Health insurance plans in U. S. (2007) -68% private -60% employment based -28% govt.

plans (medicare, medicaid) -85% of people are covered by some plan and some people are covered by more than one insurance plan Worker's comp -1908First health insurance policy -1860 *the Franklin Health Assurance company of Massachusetts was the first commercial insurance company to provide healthcare coverage for injuries not resulting in death FECA -1916 -federal employees' compensation act -replaced 1908 workers comp legislation -civilian employees of the federal govt.

were provided medical care, survivor's benefits and compensation for lost wages First Blue Cross policy -1929Blue shield -1939 -founded in CA -lumbar and mining camps of pacific NW -employers wanted to provide medical care for their workers, so they paid monthly fees to medical service bureaus, which were composed of groups of physicians Hill-Burton Act -1946 *provided federal grants for modernizing hospitals that had become obsolete b/c of lack of capital investment during the great depression and WWII -in return, facilities were required to provide services free or at reduced rates to patients unable to pay for care Taft-Hartley Act Major medical insurance -1947 -amended the national labor relations act of 1932 restoring a more balanced relationship b/w labor and management --> third-party administrators (TPAs) which administer healthcare plans and process claims, thus serving as a system of checks and balances for labor and managment -1950 - provided coverage for catastrophic or prolonged illness and injuries.

Most of these programs incorporate LARGE DEDUCTIBLES and lifetime maximum amountsdeductible -the amount for which the patient is financially responsible before an insurance policy provides paymentlifetime maximum amount -the maximum benefits payable to a health plan participant Medicare -1966 *provides healthcare to Americans over the age of 65Medicaid -1966 -a cost-sharing program b/w the federal and state govts.

to provide healthcare services to low-income Americans CHAMPUS (Civilian Health and Medical Program -- Uniformed Services) -1966 -designed as a benefit for dependents of personnel serving in the armed forces and uniformed branches of the Public health service and the national oceanic and atmospheric administration -Now called TRICAREHMO act of 1973 -Health Maintenance Organization Assistance Act of 1973 -authorized federal grants and loans to private organizations that wished to develop health maintenance organizations (HMOs), which are responsible for providing healthcare services to subscribers in a given geographic area for a fixed fee CMS-1500 -CMS requires providers to use this to submit medicare claims E/M codes -1991 -evaluation and management - which describes patient encounters with providers for the purpose of evaluation and management of general health status RBRVS -1992 -Resource-Based Relative Value Scale system -payment system that reimburses physicians' practice expenses based on relative values for 3 components of each physician's service: physician, work, practice expense, and malpractice insurance expense -fee schedule - list of predetermined payments based a fee assigned to each CPT code HIPAA -Health insurance Portability and Accountability Act of 1996 (HIPAA) -mandates regulations that govern privacy, security, and electronic transactions standards for healthcare information -primary intent is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs The primary purpose of the patient record ____ secondary purposes ______ -to provide for continuity of care -record includes patient demographic (identification) data, documentation to support diagnosis and justify tx provided, and the RESULTS of the tx provided -evaluating the quality of patient care -providing data for research -providing info to 3rd party payers for reimbursement -serving medico-legal interests of the patient, facility and providers of caremedical necessity -the patient's diagnosis must also justify diagnostic and/or therapeutic procedures or services provided *requires providers to document services or supplies that are: -proper and needed for the diagnosis or tx of a medical condition -provided for the diagnosis, direct care, and tx of a medical condition -consistent with standards of good medical practice in the local area -not mainly for the convenience of the physician or healthcare facilityproblem-oriented record (POR) -systematic method of documentation w/ 4 components 1) Database - chief complaint, present conditions and diagnoses, social data, past medical and social hx, review of systems, physical examination, baseline laboratory data 2) Problem list - table of contents (numbered list of patient's problems 3) Initial plan -Diagnostic/management plans (plans to learn more about the pts condition and the management of conditions -therapeutic plans (specific medications, goals, procedures, therapies) -Patient education plans - plans to educate the patient about conditions for which he or she is being treated 4) Progress notes -SOAP NOTEElectronic health record (EHR) -facilitates RECORD LINKAGE, which allows patient info to be created at different locations according to a unique patient ID number -more global focus (i.e.

automates and streamlines a provider's workflow, ensuring that all clinical information is communicated, supports collection of data for uses other than clinical careelectronic medical record (EMR) -more narrow focus -the patient record created for a SINGLE medical practice using a computer, keyboard, a mouse, optical pen device, voice recognition system, scanner, and/or touch screen Total practice management software (TPMS) -used to generate the EMR *automates: -registering patients -scheduling appointments -generating insurance claims and patient statements -processing payments from patient and third party payers -producing administrative and clinical reports Personal health record (PHR) -web-based application -allows individuals to maintain and manage their health info (and that of other for whom they are authorized, such as family members) in a private, secure, and confidential manner Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) -enacted a PPS (prospective payment system) - which issues a PREDETERMINED payment for services Chapter 12 Commercial Insurance Start Commercial health insurance -covers the medical expenses of individuals (e.g.

private health insurance) and groups (e.g. employer group health insurance)Individual health insurance policies are regulated by individual states and include the following: 1) Fee-for-service (or indemnity) insurance -traditional health insurance that covers a portion of services, such as inpatient hospitalizations or physician visits, with the patient paying the remaining costs 2) High-risk-pools (""last resort"" health insurance for individuals who cannot obtain coverage due to a serious medical condition; certain eligibility requirements apply, such as refusal by at least one or two insurance companies 3) Managed Care 4) Association health insurance - offered to members of a professional association and marketed to small business owners as a way to provide coverage to employees; however, these plans are not subject to the same regulations as group health insurance plans and, therefore, are more risky Employer-based group health insurance -covers all employees, regardless of health status, and cannot be cancelled if an employee becomes ill -limits exclusions for pre-exisiting conditions (can only exclude for 12-18 months) -Is portable -offers COBRA continuation of coverage (employee must be offered COBRA continuation coverage that lasts for 18-36 months, depending on the employee's situation -has employer limited plan options (e.g.

prescription drug plan that covers a certain list of medications, called a formulary)automobile Insurance - a contract b/w an individual and an insurance company whereby the individual pays a premium and, in exchange, the insurance company agrees to pay for specific car-related financial losses during the term of policy -covers medial expenses associated with automobile accidents (PIP Personal Injury protection ) - usually cover up to a certain limit **The automobile insurance company's MEDICAL ADJUSTER reviews healthcare bills submitted to the insurance company to determine coverage (may cover ambulatory expenses, medical supplies, lab services, ER care, physical therapy, etc)Disability insurance -reimbursement for income lost as a result of a temporary or permanent illness or injury *when pts.

are treated for disability diagnoses and other medical problems, separate patient records must be maintained -also a good idea to organize the financial records separately for these patients -Disability insurance generally does not pay for healthcare services, but provides the disabled person with financial assistance Criteria: -unable to do regular or customary work for a certain number of days (depends on policy) -Was employed when disabled -under care of physician during initial disability; must remain under care to continue to receive benefits -has disability insurance coverage itself -processes a claim within 'x' number of days (policy specific) -Has the licensed provider complete the disability medical certification document (s) Can be found ineligible for disability benefits if: -are claiming or receiving unemployment insurance -became disabled while committing a crime that resulted in a felony conviction -are receiving workers' compensation benefits at a weekly rate equal to or greater than the disability rate -are in jail, prison or a recovery home b/c of a convicted crime -fail to have an independent medical exam when requested to do so Base period -usually covers 12 months and is divided into 4 consecutive quarters beginning day disability begins -includes taxed wages paid ~6-18 months before the disability claim begins -does not include wages being paid at the time the disability began *A final payement notice is sent when records show that an individual has been paid through the doctor's ESTIMATED DATE OF RECOVERY -if an individual is still disabled, then the doctor must submit appropriate documentation so that the case can be reviewed -need new claim every time become disabled Liability insurance - a policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured -employer is the insured and responsible for payment, and the patient's health insurance plan is billed as a secondary (and reimburses only the remaining costs of health care NOT covered by the insured) -there cannot be any third party negligence -in cases where negligence did occur, the liability payer determines that the incident is not covered by the negligent party's liability contract -to file a claim with a liability payer,a regular patient billing statement is often used rather than an insurance claim Subrogation -the contractual right of a third-party payer to recover healthcare expenses from a liable party (e.g.

patient is injured on the job) -third-party payers implement a ""pay and chase"" method to aggressively pursue the recovery and coordination of payment for healthcare expenses from liability payers; they review diagnosis codes on claims to det.

whether a liability payer should be considered primary Birthday rule -the policyholder whose birth month and day occurs earlier in the calendar year holds the primary policy when each parent subscribes to a different health insurance plan Blues cross / Blue Shield -Know the various plans Blue cross origin -1929 when Baylor University Hospital in Dallas, Texas, approached teachers in the dallas school with a plan that would guarantee up to 21 days of hospitilization/year for subscribers and each other dependents, in exchange for $6 annual premium -by 1948 the need for additional national coordination --> Blue Cross Association was created BCBSA -located in Chicago -merging of blue cross/blue shield in 1986 1) establishes standards for new plans and programs 2) Assists local plans w/ enrollment activities, national advertising, public education, professional relations, and statistical and research activities 3) Serves as the primary contractor for processing medicare hospital, hospice, and home healthcare claims 4) coordinates nationwide BCBS plans BCBS distinctive features 1) they maintain negotiated contracts with providers of care.

In exchange for such contracts, BCBS agrees to perform the following services -make prompt, direct payment of claims -maintain regional professional reps to assist participating providers with claim problems -provide educational seminars, workshops, billing manuals, and newsletters to keep participating providers up to date on BCBS insurance procedures 2) BCBS plans, in exchange for tax relief for their nonprofit status, are forbidden by state law from canceling coverage for an individual b/c he or she is in poor health or BCBS payments to providers have far exceeded the average.

Policies issued by the nonprofit entity can be cancelled, or an individual unenrolled, only: -When premiums are NOT PAID -If the plan can prove that fraudulent statements were made on the application for coverage 3) BCBC plans must obtain approval from their respective state insurance commissioners for any rate increases and/or benefit changes that affect BCBS members within the state.

The for profit commercial plans have more freedom to increase rates and modify general benefits without state approval (but get taxed) 4) BCBS plans must allow conversion from group to individual coverage and guarantee the transferability of membership from one local plan to another when a change in residency moves a policyholder into an area served by a different BCBS corporation Participating provider (PAR) - a healthcare provider who enters into a contract with a BCBS corporation and agrees to: 1) submit insurance claims for all BCBS subscribers 2) provide access to the provider relations dept., which assists the PAR provider in resolving claims or payment problems 3) Write off (make a fee adjustment for) the difference or balance b/w the amount charged by the provider and the approved fee established by the insurer 4) Bill patients for only the deductible and copay/coinsurance amounts that are based on BCBS-allowed fees and the full charged fee for any uncovered service In return, BCBS corporations agree to: -make direct payments to PARs -conduct regular training sessions for PAR billing staff -provide free billing manuals and PAR newsletters -maintain a provider rep. dept.

to assist with billing/payment problems -Publish the name, address, and specialty of all PARs in a directory distributed to BCBS subscribers and PARs Preferred Providers -PARs can also contract to participate in the plan's preferred provider network (PPN), a program that requires providers to adhere to managed care provisions -in this contractual agreement, the PPN provider agrees to accept the PPN allowed rate (~10% lower than the PAR allowed rate) -the provider further agrees to abide by all cost-containment, utilization, and quality assurance provisions of the PPN program **In return: the ""Blues"" agree to notify PPN providers in writing of new employer groups and hospitals that have entered into PPN contracts and to maintain a PPN directory Nonparticipating Providers (non PARs) -they expect to be paid the full fee charged for services rendered *In these cases, the patient may be asked to pay the provider in full and then be reimbursed by BCBS the allowed fee for each service, minus the patient's deductible and copayment obligations -even when the provider agrees to file the claim for the patient, the insurance company sends the payment for the claim directly to the patient and not to the provider Fee-for-Service (Traditional coverage) -selected by: 1) individuals who do not have access to a group plan 2) many small business employers -2 types of coverage within one policy: 1) Basic coverage- hospitalizations, Diagnostic lab services, X-rays, Surgical fees, Assistant surgeon fees, Obstetric care, Intensive care, newborn care, chemotherapy for cancer 2) Major medical (MM) benefits - office visits, outpatient nonsurgical treatment, physical and occupational therapy, purchase of durable medical equipment (DME), Mental health visits, allergy testing and injections, prescription drugs, private duty nursing (when medically necessary), dental care required as a result of a covered accidental injury -these are usually subject to patient deductible and copayment requirements *Some contracts include one or more RIDERS - special clauses stipulating additional coverage over and above the standard contract (common RIDERS include special accidental injury and medical emergency care coverage 1) Special accidental injury rider - covers 100% of NONSURGICAL care sought and rendered w/in 24-72 hours of the accidental injury 2) Medical emergency rider - covers immediate tx sought and received for sudden, severe, and unexpected condtions that if not treated would place the patient's health in permanent jeopardy or cause permanent impairment or dysfunction of an organ or body part BCBS Indemnity Coverage -offers CHOICE and FLEXIBILITY to subscribers who want to receive full range of benefits along with the freedom to use any licensed healthcare provider -coverage includes HOSPITAL ONLY or COMPREHENSIVE HOSPITAL and medical coverage -subscribers share the cost of benefits through coinsurance options, do not have to select a primary care provider, and do not need a referral to see a provider BCBS Managed Care Plans -managed care is a healthcare delivery system that provides health care and controls costs THROUGH A NETWORK of physicians, hospitals, and other healthcare providers -these plans include the coordinated home health and hospice care program, exclusive provider organizations, health maintenance organizations (HMO), outpatient pretreatment authorization plans, point-of-service plans, preferred provider organizations, and second surgical opinions *Exclusive provider organization (EPO) - similar to a health maintenance organization that provides healthcare services through a network of doctors, hospitals, and other healthcare providers, except that members are NOT REQUIRED TO SELECT a primary care provider, and they do not need a referral to see a specialist.

HOWEVER, they must obtain services from EPO providers only or the patient is responsible for charges *HMO - fixed fee for services *Outpatient pretreatment authorization plan (OPAP) - requires preauthorization of outpatient physical, occupational, and speech therapy services -in addition OPAP requires periodic tx/progress plans to be filed -also known as prospective authorization or precertification *POS (point-of-service plan) - allows subscribers to choose, at the time medical services are needed, whether they will go to a provider w/in the plan's network or outside the network -subscribers choose a primary care provider (PCP) from the payer's PCP list (PCP is gatekeeper) -when the subscriber goes outside the network to seek care, out of pocket expenses and copayments generally increase -provide a full range of inpatient and outpatient services *PPO (preferred provider organizations) -offers discounted healthcare services to subscribers who use designated healthcare providers (who contract with PPO) but also provides coverage for services rendered by healthcare providers who are not part of the PPO network -Sometimes described as as a subscriber-driven program, and BCBS substitutes the terms subscriber (or member) for POLICYHOLDER - the subscriber (member) is responsible for remaining within the network of PPO providers and must request referrals to PPO specialists whenever possible -subscriber must also adhere to the managed care requirements of the PPO policy, such as obtaining required second surgical opinions and/or hospital admission review -failure to adhere to these requirements will result in denial of the surgical claim or reduced payment to the provider.

Patient is responsible for the difference or balance b/w the reduced payment and the normal PPO allowed rate * Second Surgical opinion (SSO) - a requirement necessary when a patient is considering elective, nonemergency surgical care -if a second opinion is not obtained prior to surgery, the patient's out-of-pocket expenses may be greatly increased Federal Employee Program -an employer-sponsored health benefits program established by an Act of Congress in 1959 -FEP is underwritten and administered by participating insurance plans that are called LOCAL PLANS (e.g.

Blue Cross and Blue Shield plans - they are just one of many who reimburse healthcare services) -claims are submitted to local plans that serve the location where the patient was seen (called a SERVICE LOCATION) regardless of the member's FEP plan affiliation -FEP cards contain the phrase ""Government-Wide Service Benefit Plan"" under the BCBS trademark -they have ID numbers that begin with the letter ""R"" followed by 8 numeric digits -All Id cards contain the name of the govt.

employee -dependent's names do not appear on the card * 3 digit enrollment code options (4) 1) 101 - individual, high option Plan 2) 102 - Family, High option Plan 3) 104 - Individual Standard (Low) Option Plan 4) 105 - Family Standard (Low) Option Plan -considered a fee-for-service plan and has generally operated as a PPO plan - patient is responsible for ensuring that pre-certification is obtained for all hospitalizations except routine maternity care, home health and hospice care, and emergency hospitilization w/in 48 hours Medicare Supplemental Plans -BCBS offers several federally designed and regulated Medicare Supplemental Plans -they augment the medicare program by paying for medicare deductibles and copayments -better known as Medigap Plans (usually identified by the word Medigap on the patient's plan ID card)Healthcare Anywhere -allows members of the independently owned and operated BCBS plans to have access to healthcare benefits throughout the United States and around the world, depending on their home plan benefits **The Blue Card program enables such members obtaining healthcare services while traveling or living in another BCBS plan's service area to receive the benefits of their home Plan contract and to access local provider networks **The Away From Home Care Program allows the participating BCBS Plan members who are temporarily residing outside of their home HMO service area for at least 90 days to temporarily enroll with a local HMO **Blue Worldwide Expat - provides global medical coverage for active employees and their dependents who spend more than 6 months outside the U. S. Deadline for filling claims -customarily one year from the date of service, unless otherwise specified in the subscriber's or provider's contracts Forms Used Most BCBS payers currently accept the CMS-1500 claim Inpatient and Outpatient coverage -may vary according to the plan.

Many plans require second surgical opinions and prior authorization (Prior authorization is a requirement that your physician obtain approval from your health plan to prescribe a specific medication for you. Without this prior approval, your health plan may not provide coverage, or pay for, your medication.

)Deductible The deductible will vary according to the BCBS plan. Consult the BCBS bill- ing manual or eligibility status computerized phone bank for specific patient requirements. Patients enrolled in PPO plans may have no applicable deduct- ibles for certain preventive medicine services. Copayment/Coinsurance Patient copayment/coinsurance requirements vary according to the patient plan.

The most common coinsurance amounts are 20 percent or 25 percent, although they may be as high as 50 percent for mental health services on some policies. Allowable Fee Determination Patient copayment/coinsurance requirements vary according to the patient plan. The most common coinsurance amounts are 20 percent or 25 percent, although they may be as high as 50 percent for mental health services on some policies.

Non PARs may collect the full fee from the patient. BCBS payments are then sent directly to the patient. Assignment of Benefits All claims filed by participating providers qualify for an assignment of benefits to the provider.

This means that payment is made directly to the provider by BCBS. Special Handling 1. Make it a habit and priority to retain a current photocopy of the front and back of all patient ID cards in the patient's file. 2. Claims for Blue Card patients with more than one insurance policy must be billed directly to the plan from which the program originated. Use the CMS-1500 claim. 3. Non PARs must bill the patient's plan for all non-national account patients with Blue Cards. 4. Rebill claims not paid within 30 days. 5. Some mental health claims are forwarded to a third-party administra- tor (TPA), a company that provides administrative services to healthcare plans and specializes in mental health case management. Check the back of the ID card and billing manual for special instructions. Medicare Medicare, the largest single medical benefits program in the United States, is a federal program authorized by Congress and administered by the Centers for Medicare and Medicaid Services (CMS, formerly HCFA).

CMS is responsible for the operation of the Medicare program and for selecting Medicare administrative contractors (MACs) to process Medicare fee-for-service Part A, Part B, and durable medicine equipment (DME) claims.

Medicare is a two-part program: ● Medicare Part A reimburses institutional providers for inpatient, hospice, and some home health services. ● Medicare Part B reimburses institutional providers for outpatient services and physicians for inpatient and office services. Medical Hospital Insurance (Medicare Part A) pays for inpatient hospital critical care access; skilled nursing facility stays; hospice care; and some home health care.

(Submit UB-04 [CMS-1450] claim for services. )Medicare Medical Insurance (Medicare Part B) pays for doctors' services; outpatient hospital care; durable medical equipment; and some medical services that are not covered by Part A.

(Submit CMS-1500 claim for services. )Medicare Advantage (Medicare Part C) formerly called Medicare+Choice, includes managed care and private fee-for-service plans that provided contracted care to Medicare patients. Medicare Advantage is an alternative to the original Medicare plan reimbursed under Medicare Part A.

(Submit CMS-1500 or UB-04, depending on type of services provided. )Medicare Prescription Drug Plans (Medicare Part D) add prescription drug coverage to the Original Medicare Plan, some Medicare Cost Plans, some Medicare Private Fee-for-Service Plans and Medicare Medical Savings Account Plans.

(Medicare beneficiaries present a Medicare prescription drug discount card to pharmacies. )Medigap Medicare beneficiaries can also obtain supplemental insurance, called Medigap, which helps cover costs not reimbursed by the original Medicare plan. Depending on the region of the country, more than one Medicare health plan may be available to enrollees. General Medicare Eligibility 1. Individuals or their spouses to have worked at least 10 years in Medicare-covered employment. 2. Individuals to be the minimum of 65 years old. 3. Individuals to be citizens or permanent residents of the United States.

*Individuals can also qualify for coverage if they are younger than 65 and have a disability or End-Stage Renal Disease. The Social Security Administration (SSA) (an agency of the federal government) bases its definition of disability on an individual's ability to work; an individual can be considered disabled if unable to do work as before and if it is determined that adjustments cannot be made to do other work because of a medical condition (s).

In addition, the disability must last or be expected to last a year or to result in death. There is no premium for Part A if individuals meet one of these conditions; however, they do pay for Part B coverage.

The Part B monthly premium changes annu- ally and is deducted from Social Security, Railroad Retirement, or Civil Service Retirement checks. Medicare Part A coverage is available to individuals age 65 and over who: ● Are already receiving retirement benefits from Social Security or the Railroad Retirement Board (RRB).

● Are eligible to receive Social Security or Railroad benefits but have not yet filed for them. ● Had Medicare-covered government employment. Medicare Part A coverage is available to individuals under age 65 who have: ● Received Social Security or RRB disability benefits for 24 months.

● End-Stage Renal Disease and meet certain requirements. Electronic data interchange (EDI) EDI is the most efficient and cost-effective way to make eligibility information available because provider agreements ensure privacy safeguards. Provider Telephone inquiries for Medicare Eligibility Eligibility information is also available over the telephone, subject to con- ditions intended to ensure the protection of the beneficiary's privacy rights.

The eligibility information that can be released by telephone is limited to that information available via EDI.

The provider's name and identification number must be verified and the following information obtained about each beneficiary: ● Last name and first initial ● Date of birth ● HICN (health insurance claim number) ● Gender Automatic Enrollment Individuals not yet age 65 who already receive Social Security, Railroad Retirement Board, or disability benefits are automatically enrolled in Part A and Part B effective the month of their 65th birthday.

About three months before the 65th birthday, or the 24th month of disability, individuals are sent an initial enrollment package that contains information about Medicare, a questionnaire, and a Medicare card. If the individual wants both Medicare Part A (hospital insurance) and Part B (supplemental medical insurance), he or she just signs the Medicare card and keeps it in a safe place.

Individuals who do not want Part B coverage (because there is a monthly premium associated with it) must follow the instructions that accompany the Medicare card; these instructions direct the individual to mark an ""X"" in the refusal box on the back of the Medicare card form, sign the form, and return it with the Medicare card to the address indicated.

The individual is then sent a new Medicare card showing coverage for Part A only. Medicare Part A coverage is available to individuals age 65 and over who: ● Are already receiving retirement benefits from Social Security or the Railroad Retirement Board (RRB). ● Are eligible to receive Social Security or Railroad benefits but have not yet filed for them. ● Had Medicare-covered government employment.

Initial enrollment period Individuals who do not receive Social Security, Railroad Retirement Board, or disability benefits must apply for Medicare Part A and Part B by contacting the Social Security Administration (or Railroad Retirement Board) approximately three months before the month in which they turn 65 or the 24th month of disability. Upon applying for Medicare Part A and Part B, a seven-month initial enrollment period (IEP) begins that provides an opportunity for the individual to enroll in Medicare Part A and/or Part B.

**Those who wait until they actually turn 65 to apply for Medicare will cause a delay in the start of Part B coverage, because they will have to wait until the next general enrollment period (GEP), which is held January 1 through March 31 of each year; Part B coverage starts on July 1 of that year.

The Part B premium is also increased by 10 percent for each 12-month period during which an individual was eligible for Part B coverage but did not participate. Under certain circumstances, individuals can delay Part B enrollment with- out having to pay higher premiums. ● Individuals age 65 or older who are working, or whose spouse is working, and who have group health insurance through the employer or union.

● Disabled individuals who are working and who have group health insurance or who have group health insurance coverage from a working family member. **if Part B enrollment is delayed for one of these reasons, individuals can enroll anytime during the special enrollment period (SEP), a set time when they can sign up for Medicare Part B, if they did not enroll in Part B during the initial enrollment period.

**For individuals who enroll in Medicare Part B while cov- ered by a group health plan or during the first full month after group health plan coverage ends, coverage starts on the first day of the month of enrollment.

Individuals can also delay the start date for Medicare Part B coverage until the first day of any of the subsequent three months. If the individual enrolls during any of the seven remaining months of the special enrollment period, coverage begins the month after enrollment.

If an individual does not enroll during the special enrollment period, they must wait until the next general enrollment period (January 1 through March 31 of each year), and they may be required to pay a higher Medicare Part B premium.

Qualified Medicare beneficiary program (QMBP) (helps individuals whose assets are not low enough to qualify them for Medicaid by requiring states to pay their Medicare Part A and B premiums, deductibles, and coinsurance amounts)Specified low-income Medicare beneficiary (SLMB) (helps low-income individuals by requiring states to pay their Medicare Part B premiums)Qualified individual (QI) (helps low-income individuals by requiring states to pay their Medicare Part B premiums)Qualified disabled working individual (QDWI) (helps individuals who received Social Security and Medicare because of disability, but who lost their Social Security benefits and free Medicare Part A because they returned to work and their earn- ings exceed the limit allowed, by requiring states to pay their Medicare Part A premiums)Asset limits for all programs are the same Personal assets (e.g., cash, money in the bank, stocks, bonds, and so on) cannot exceed $4,000 for an indi- vidual or $6,000 for married couples.

Exclusions include a home, household goods and personal belongings, one car, a life insurance policy up to a cash value of $1,500 per person, a prepaid burial plan (unlimited if irrevocable; up to $1,500 if revocable), a burial plot, and retroactive Social Security or SSI benefits (for six months after qualification in a Medicare savings program Medicare Part A Medicare Part A (Medicare Hospital Insurance) helps cover inpatient care in acute care hospitals, critical access hospitals, and skilled nursing facilities.

It also covers hospice care and some home healthcare services. Hospitalizations Medicare pays only a portion of a patient's acute care and critical access hos- pital (CAH) inpatient hospitalization expenses, and the patient's out-of-pocket expenses are calculated on a benefit-period basis.

A benefit period begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days.

(Some Medicare literature uses the term spell of illness, formerly called ""spell of sickness,"" in place of ""benefit period."") After 90 continuous days of hospitalization, the patient may elect to use some or all of the allotted lifetime reserve days, or pay the full daily charges for hospital- ization.

Lifetime reserve days (60 days) may be used only once during a patient's lifetime and are usually reserved for use during the patient's final, terminal hospital stay.

**The 2010 Part A deductibles per benefit period are: Days 1-60 ($1,100 total) Days 61-90 ($275/day) Days 91-150 (Patient pays total charges, or elects to use lifetime reserve days at $550/day) 150+ continuous days (Patient pays total charges) A person who has been out of the hospital for a period of 60 consecutive days will enter a new benefit period if rehospitalized, and the expenses for the first 90 days under this new benefit period are the same as stated earlier.

Persons confined to a psychiatric hospital are allowed 190 lifetime reserve days instead of the 60 days allotted for a stay in an acute care hospital.

Skilled Nursing Facility Individuals who become inpatients at a skilled nursing facility after a three- day-minimum acute hospital stay, and who meet Medicare's qualified diagnosis and comprehensive treatment plan requirements, pay 2010 rates of: Days 1-20 - Nothing Days 21-100 - $137.50/day Days 101+ - Full Daily Rate Home Health Services Individuals receiving physician-prescribed, Medicare-covered home health ser- vices have no deductible or coinsurance responsibilities for services provided.

Patients must be confined to the home, but they do not have to be hospitalized in an acute care hospital before qualifying for home health benefits. The patient is responsible for a 20 percent deductible of the approved amount for durable medical equipment. Medicare Part B also covers some home health ser- vices if the patient is not covered by Medicare Part A. Hospice Care All terminally ill patients qualify for hospice care.

Hospice is an autonomous, centrally administered program of coordinated inpatient and outpatient pallia- tive (relief of symptoms) services for terminally ill patients and their families. This program is for patients for whom the provider can do nothing further to stop the progression of disease; the patient is treated only to relieve pain or other discomfort.

In addition to medical care, a physician-directed interdisci- plinary team provides psychological, sociological, and spiritual care.

Medicare limits hospice care to four benefit periods, which include: ● ● ● Two periods of 90 days each, One 30-day period, A final ""lifetime"" extension of unlimited duration Hospice Patient is responsible for: -5 percent of the cost of each prescription for symptom management or pain relief, but not more than $5 for any prescription. -5 percent of the Medicare payment amount for inpatient respite care for up to five consecutive days at a time.

Patients who withdraw from the hospice program during the final benefit period are considered to have exhausted their hospice benefits. A patient who is receiving hospice benefits is not eligible for Medicare Part B services except for those services that are totally unrelated to the terminal illness.

When a patient chooses Medicare hospice benefits, all other Medicare benefits stop, with the exception of physician services or treatment for conditions not related to the patient's terminal diagnosis.

Medicare Part B Medicare Part B (Medicare Medical Insurance) helps cover physician services, outpatient hospital care, and other services not covered by Medicare Part A, including physical and occupational therapy and some home health care for patients who do not have Medicare Part A. Medicare enrollees whose incomes are more than $85,000 (individual) or $170,000 (couple) pay higher Part B premiums than people with lower incomes. In hospital outpatient settings, the coinsurance amount is based on a national median amount per ambulatory pay- ment classification (APC), which could be higher than 20 percent. Hospitals have the option of charging patients either the 20 percent or the higher national median coinsurance amount.

Regardless, Medicare will reim- burse hospitals the difference between the Medicare-approved amount and the national coin- surance of 20 percent. However, if the hospital collects the higher median coinsurance amount from the patient, Medicare will reduce its reimbursement accordingly.

Since 1992, Medicare has reimbursed provider services according to a _____ phy- sician fee schedule (also called the Resource-Based Relative Value Scale, RBRVS), which also limits amounts nonparticipating providers (non PARs) can charge beneficiaries.

Reimbursement under the fee schedule is based on relative value units (RVUs) that consider resources used in providing a service (physician work, practice expense, and malpractice expense). Medicare Part C -Medicare Part C includes managed care plans, such as Medicare health mainte- nance organizations (HMOs).

Medicare Advantage Plans (Medicare Part C, formerly called Medicare+Choice as established by the Balanced Budget Act of 1997) are health plan options that are approved by Medicare but managed by private companies. These plans provide all Medicare Part A (hospital) and Medicare Part B (medical) coverage and must cover medically-necessary services. There is no need to purchase a Medigap policy. Medicare Advantage Plans may: ● Require referrals to see specialists.

● Offer lower premiums or copayments and deductibles than the Original Medicare Plan. ● Have networks, which means patients may have to see doctors who belong to the plan or go to certain hospitals to get covered services. ● Offer extra benefits, such as prescription drug coverage. ● Coordinate patient care, using networks and referrals, which can help with overall care management and result in cost savings.

Medicare enrollees have the option of enrolling in one of the following plans: ● Medicare health maintenance organization (HMO) ● Medicare medical savings account (MSA) plan ● Medicare special needs plan ● Preferred provider organization (PPO) ● Private fee-for-service (PFFS) plan Medicare medical savings account (MSA) A Medicare Medical Savings Account (MSA) is used by an enrollee to pay healthcare bills, while Medicare pays the cost of a special healthcare policy that has a high deductible (not to exceed $6,000).

Medicare also annually deposits into an account the difference between the policy costs and what Medicare pays for an average enrollee in the patient's region. The money deposited annually by Medicare into an MSA is managed by a Medicare-approved insurance com- pany or other qualified company.

It is not taxed if the enrollee uses it to pay qualified healthcare expenses. It may earn interest or dividends, and any funds left in the account at the end of a calendar year are carried over to the next year.

The enrollee pays healthcare expenses using money from the MSA account until the high deductible has been met. (If the MSA is exhausted before the high deductible has been met, the enrollee pays out of pocket until the deductible has been met.)

Once the deductible has been met, the insurance policy pays healthcare expenses. **MSA enrollees are required to pay the monthly Medicare Part B premium. Private fee-for-service (PFFS) plans are offered by private insurance com- panies and are available in some regions of the country. Medicare pays a pre-established amount of money each month to the insurance company, which decides how much it will pay for services. Such plans reimburse providers on a fee-for-service basis and are authorized to charge enrollees up to 115 percent of the plan's payment schedule.

Medicare special needs plans cover all Medicare Part A and Part B health care for individuals who can benefit the most from special care for chronic illnesses, care management of multiple diseases, and focused care management. Such plans may limit membership to individuals who: ● Are eligible for both Medicare and Medicaid (Medi-Medi coverage).

● Have certain chronic or disabling conditions. ● Reside in certain institutions (e.g., nursing facility). Medicare Part D Medicare Prescription Drug Plans (Medicare Part D) offer prescription drug cov- erage to all Medicare beneficiaries that may help lower prescription drug costs and help protect against higher costs in the future.

Medicare Part D is optional, and individuals who join a Medicare drug plan pay a monthly premium. (Individuals who decide not to enroll in a Medicare prescription drug plan when first eligible may be required to pay a penalty if they choose to join later.) Medicare prescription drug plans are administered by insurance companies and other private companies approved by Medicare.

There are two ways to obtain Medicare prescription drug coverage: 1. Join a Medicare Prescription Drug Plan that adds coverage to the origi- nal Medicare plan, some Medicare private fee-for-service plans, some Medicare cost plans, and Medicare medical savings account plans.

This plan requires subscribers to pay a monthly premium and an annual deductible. 2. Join a Medicare Advantage Plan (e.g., HMO) that includes prescrip- tion drug coverage as part of the plan. Monthly premiums and annual deductibles will vary, depending on the plan. In addition, all Medicare health care (including prescription drug coverage) is pro- vided by such plans.

Medicare Cost Plan A Medicare Cost Plan is a type of HMO that works in much the same way and has some of the same rules as a Medicare Advantage Plan. In a Medicare Cost Plan, if the individual receives health care from a non-network provider, the Original Medicare Plan covers the services.

The individual pays Medicare Part A and Part B coinsurance and deductibles.demonstration/pilot program a special project that tests improvements in Medicare coverage, payment, and quality of care. Some follow Medicare Advantage Plan rules, but others do not. Demonstrations usually apply to a specific group of people and/or are offered only in specific areas.

They also include pilot programs for individuals with multiple chronic illnesses designed to reduce health risks, improve quality of life, and provide healthcare savings. Programs of All-Inclusive Care for the Elderly (PACE) combine medical, social, and long-term care services for frail people who live and receive health care in the community. PACE is a joint Medicare and Medicaid option in some states. To be eligible, an individual must be: ● 55 years old, or older.

● A resident of the service area covered by the PACE program. ● Able to live safely in the community.

● Certified as eligible for nursing home care by the appropriate state agency. The goal of PACE is to help people stay independent and live in their commu- nity as long as possible, while receiving the high quality care they need. Medigap (or Medicare Supplementary Insurance, MSI) offered by commercial health insurance companies and some BCBS companies. It is designed to supplement Medicare benefits by paying for services that Medicare does not cover. Although Medicare covers many healthcare costs, enrollees must still pay Medicare's deductibles and coinsurance amounts.

In addition, there are many healthcare services that Medicare does not cover. A Medigap policy provides reimburse- ment for out-of-pocket costs not covered by Medicare, in addition to those that are the beneficiary's share of healthcare costs.

There are 12 Medigap poli- cies (Table 14-3), each offering a different combination of benefits. (Premium amounts are determined by payers. )Medicare SELECT a type of Medigap insurance that requires enrollees to use a network of providers (doctors and hospitals) in order to receive full benefits.

Because of this requirement, Medicare SELECT policies may have lower premi- ums. However, if an out-of-network provider is used, Medicare SELECT gener- ally will not pay benefits for nonemergency services.

Medicare, however, will still pay its share of approved charges. Currently, Medicare SELECT is available only in limited geographic areas of the country. Participating Provider (PAR) Medicare has established a participating provider (PAR) agreement in which the provider contracts to accept assignment on all claims submitted to Medicare. By 2000, more than 85 percent of all physicians, practitioners, and suppliers in the United States were PARs. Congress mandated special incentives to increase the number of healthcare providers signing PAR agreements with Medicare, including: ● Direct payment of all claims. ● A 5 percent higher fee schedule than for nonparticipating providers. ● Bonuses provided to Medicare administrative contractors (MACs) for recruit- ment and enrollment of PARs.

● Publication of an annual, regional PAR directory (Med PARD) made available to all Medicare patients.

● A special message printed on all unassigned Medicare Summary Notice (MSN) forms mailed to patients, reminding them of the reduction in out-of-pocket expenses if they use PARs and stating how much they would save with PARs. ● Hospital referrals for outpatient care that provide the patient with the name and full address of at least one PAR provider each time the hospital provides a referral for care.

● Faster processing of assigned claims. Regardless of the type of Medicare Part B services billed, PARs have ""one-stop"" billing for beneficiaries who have Medigap coverage and who assign both Medicare and Medigap payments to PARs. After Medicare has made payment, the claim will automatically be sent to the Medigap insurer for payment of all coinsurance and deductible amounts due under the Medigap policy.

The Medigap insurer must pay the PAR directly.non PARs Medicare nonparticipating providers (non PARs) may elect to accept assignment on a claim-by-claim basis, but several restrictions must be adhered to: ● Non PARs must file all Medicare claims. ● Fees are restricted to not more than the ""limiting charge"" on nonassigned claims. ● Balance billing of the patient by a non PAR is forbidden.

● Collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim. ● Patients must sign a Surgical Disclosure Notice for all nonassigned surgical fees over $500. ● Non PARs must accept assignment on clinical laboratory charges. Limiting Charge Nonparticipating physicians who do not accept assignment on Medicare claims are subject to a limit (established by federal law) on what can be charged to ben- eficiaries for covered services.

The Medicare-allowed fee for non PARs is 5 per- cent below the PAR fee schedule, but the non PAR physician may charge a maximum of 15 percent above the non PAR approved rate (or 10 percent above the PAR fee schedule).

The limiting charge is the maximum fee a non PAR may charge for a covered service. It applies regardless of who is responsible for pay- ment and whether Medicare is primary or secondary. *HIPAA alert - With the passage of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Congress increased the potential fine from $2,000 to $10,000 if a non PAR does not heed Medicare administrative contractor (MAC) warnings to desist from fla- grant abuse of the limiting charge rules.

Accepting Assignment on a claim A nonparticipating provider who agrees to accept assignment on a claim will be reimbursed the Medicare-allowed fee. The non PAR may also collect any unpaid deductible and the 20 percent coinsurance determined from the Medicare Physician Fee Schedule (MPFS).

If the non PAR collects the entire charge at the time of the patient's visit, the assigned status of the claim is voided and the non PAR limiting fee is then in effect. The non PAR may also be subject to a fine or may be in violation of MPFS requirements. The non PAR cannot revoke the agreement for an assigned claim unless it is by mutual written consent of the provider and the beneficiary.

Even then, such an agreement must be communicated to the MAC before the MAC has determined the allowed amount.

Providers who repeatedly violate the assign- ment agreement could be charged and found guilty of a misdemeanor, which is punishable by a fine, imprisonment, or both.

In addition, a criminal violation may result in suspension from Medicare participation. The following practitioners who submit claims for services must accept assignment: ● Anesthesiologist assistants ● Certified nurse midwives ● Certified registered nurse anesthetists ● Clinical nurse specialists ● Clinical psychologists ● Clinical social workers ● Mass immunization roster billers ● Nurse practitioners ● Physician assistants ● Registered dietitians Providers who submit claims for the following services must accept assignment: ● ambulance services ● Ambulatory surgical center services ● Clinical diagnostic laboratory services ● Home dialysis supplies and equipment ● Medications ● Physician lab services ● Physician services to Medicare/Medicaid (Medi-Medi) crossover patients Waiver and medicare billing contracts Medicare law specifically states that non PARs are subject to sanctions, includ- ing fines and exclusions from the Medicare program, if they require patients to sign agreements stating that the patient waives the right to have the non PAR provider file the patient's Medicare claims or that the patient agrees to pay charges for services that are in excess of the non PAR charge limits.

Privacy Act In addition to the other restrictions, the Privacy Act of 1974 forbids the Medicare administrative contractor (MAC) from disclosing the status of any unassigned claim beyond the following: ● Date the claim was received by the MAC ● Date the claim was paid, denied, or suspended ● General reason the claim was suspended The non PAR provider will not be told payment amounts or approved charge information.

Surgical Disclosure Notice Providers must notify beneficiaries in writing of projected out-of-pocket expenses for elective surgery and noncovered procedures when the charge for surgery is $500 or more. This notification is required of both surgeons and assistant sur- geons. For Medicare purposes, elective surgery is defined as a surgery that: ● Can be scheduled in advance; ● Is not an emergency; and ● If delayed, would not result in death or permanent impairment of health.

The Omnibus Budget Reconciliation Act (OBRA) of 1986 requires the following information to be provided in writing to the patient: ● Estimated actual charge for surgery ● Estimated Medicare payment ● Excess of the provider's actual charge as compared with the approved charge ● Applicable coinsurance amount ● Beneficiary's out-of-pocket expenses Non PARs must document the receipt and acknowledgment of this information by having the beneficiary or the beneficiary's representative sign and date a Surgical Disclosure Notice (Figure 14-1).

A copy of the signed and dated notice must be maintained and provided upon request from the MAC. If the non PAR fails to properly notify the beneficiary prior to performing surgery, any money collected from the beneficiary that exceeds the Medicare-approved amount must be refunded. Failure to make the appropriate refund could result in civil monetary penalties and/or exclusion from the Medicare program.

Mandatory Claims Submission Federal law requires that all providers and suppliers submit claims to Medicare if they provide a Medicare-covered service to a patient enrolled in Medicare Part B. This regulation does not apply if the: ● Patient is not enrolled in Part B. ● Patient disenrolled before the service was furnished.

● Patient or the patient's legal representative refuses to sign an authorization for release of medical information. ● Provider opts out of the Medicare program, and those patients enter into private contracts with the provider (see section on Private Contracting). An exception may occur if a patient refuses to sign an authorization for the release of medical information to Medicare.

However, if the patient later opts to sign a Medicare authorization and requests that claims for all prior services be filed with Medicare, the request must be honored. Private Contracting Under the Balanced Budget Act of 1997, physicians were provided the option of withdrawing from Medicare and entering into private contracts with their Medicare patients.

As of 2003, dentists, optometrists, and podiatrists were added to the list of providers who may opt out of Medicare. This Medicare private contract is an agreement between the Medicare beneficiary and a physician or other practitioner who has ""opted out"" of Medicare for two years for all covered items and services furnished to Medicare beneficiaries.

This means that the physician/practitioner will not bill for any service or supplies provided to any Medicare beneficiary for at least two years. Under a private contract: ● No Medicare payment will be made for services or procedures provided to a patient.

● The patient is required to pay whatever the physician/practitioner charges, and there is no limit on what the physician/practitioner can charge for Medicare approved services (the limiting charge will not apply).

● Medicare managed care plans will not pay for services rendered under a private contract. ● No claim is to be submitted to Medicare, and Medicare will not pay if a claim is submitted. ● Supplemental insurance (Medigap) will not pay for services or procedures ren- dered. ● Other insurance plans may not pay for services or procedures rendered.

The private contract applies only to services and procedures rendered by the physician or practitioner with whom the patient signed an agreement. Patients cannot be asked to sign a private contract when facing an emergency or urgent health situation. If patients want to pay for services that the original Medicare plan does not cover, the physician does not have to leave Medicare or ask the patient to sign a private contract.

The patient is welcome to obtain noncovered services and to pay for those services. A physician who enters into a Medicare private contract with one patient will be unable to bill Medicare for any patient for a period of two years with the exception of emergency or urgent care provided to a patient who has not signed an agreement with the provider to forgo Medicare benefits.

In these cases, the claim for urgent or emergency care must be accompanied by an attachment explaining the following: (1) the nature of the emergency or urgent problem, and (2) a statement affirming that this patient has not signed an agreement with the provider to forgo Medicare.

If a provider submits a nonemergency or urgent care claim for any patient before the opt-out agreement becomes effective, the provider must submit claims for all Medicare patients thereafter and abide by the limiting-fee rules. If, however, the patient files the claim, the provider will not be penalized. Advanced beneficiary Notice An advance beneficiary notice (ABN) is a written document provided to a Medicare beneficiary by a supplier, physician, or provider prior to service being rendered (Figure 14-2).

The ABN indicates that the service is unlikely to be reimbursed by Medicare, specifies why Medicare denial is anticipated, and requests the beneficiary to sign an agreement that guarantees personal payment for services. A beneficiary who signs an ABN agreement will be held responsible for pay- ment of the bill if Medicare denies payment.

ABNs should be generated when- ever the supplier or provider believes that a claim for the services is likely to receive a Medicare medical necessity denial (a denial of otherwise covered services that were found to be not ""reasonable and necessary"").

**The purpose of obtaining the ABN is to ensure payment for a procedure or service that might not be reimbursed under Medicare. Cost estimates are unnecessary when an ABN is generated, because the purpose of the ABN is to document that the beneficiary has received notice that a service is unlikely to be reimbursed by Medicare. Hospital ABNs are called Hospital-Issued Notices of Noncoverage (HINN) or Notices of Noncoverage (NONC).

Do not have a patient sign an ABN when a service is never covered by Medicare. Instead, have those patients sign a different form, called the Notice of Exclusion of Medicare Benefits (NEMB). The ABN is used when the service is sometimes covered by Medicare, but the provider does not think it will be covered for that patient. It communicates that the patient will be responsible for provider charges if Medicare denies the service.

The NEMB clearly states that the service is never covered by Medicare, and that the patient is responsible for paying provider charges.

Unlike the ABN, providers are not required to have patients sign an NEMB for a never-covered Medicare service in order to bill the patient; however, use of the form makes it clear to the patient before a service is provided that the patient will have to pay for it. CAUTION: Do not obtain ABNs on every pro- cedure or service to be rendered to a patient ""just in case"" Medicare denies the claim.

To do so is con- sidered fraudulent. Experimental and Investigational Procedures Medicare law allows payment only for services or supplies that are considered reasonable and necessary for the stated diagnosis. Medicare will not cover procedures deemed to be experimental in nature. There are cases in which the provider determines that treatments or services are fully justified and such treatment options are then explained to the patient, who must pay the full cost of the non-covered procedure.

Medicare regulations specify that the provider must refund any payment received from a patient for a service denied by Medicare as investigational, unnecessary, unproved, or experimental, unless the patient agreed in writing prior to receiving the services to personally pay for such services.

Figure 14-3 shows a CMS-approved medical necessity statement. An appeal of the denial of payment must be made in writing, and if the appeal is not granted, a refund must be paid to the patient within 30 days. A refund is not required if the provider ""could not have known a specific treatment would be ruled unnecessary.

""Medicare as Primary Payer Medicare is considered the primary payer under the following circumstances: ● The employee is eligible for a group health plan but has declined to enroll, or has recently dropped coverage. ● The individual is currently employed, but is not yet eligible for group plan coverage or has exhausted benefits under the plan.

● The health insurance plan is only for self-employed individuals. ● The health insurance plan was purchased as an individual plan and not obtained through a group.

● The patient is also covered by TRICARE, which provides health benefits to retired members of the uniformed services and spouses/children of active duty, retired, and deceased service members. ● The patient is under age 65, has Medicare because of a disability or ESRD, and is not covered by an employer-sponsored plan.

● The patient is under age 65, has ESRD, and has an employer-sponsored plan but has been eligible for Medicare for more than 30 months. ● The patient has left a company and has elected to continue coverage in the group health plan under federal COBRA rules.

● The patient has both Medicare and Medicaid (Medi-Medi crossover patient). The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires employers with 20 or more employees to allow employees and their dependents to keep their employer-sponsored group health insurance coverage for up to 18 months for any of the following occurrences: ● Death of the employed spouse ● Loss of employment or reduction in work hours ● Divorce The employee or dependents may have to pay their share as well as the employ- er's share of the premium.

Medicare Conditional Primary Payer Status Medicare will award an assigned claim conditional primary payer status and process the claim under the following circumstances: ● A plan that is normally considered primary to Medicare issues a denial of pay- ment that is under appeal.

● A patient who is physically or mentally impaired fails to file a claim with the pri- mary payer. ● A workers' compensation claim has been denied, and the case is slowly moving through the appeal process.

● There is no response from a liability payer within 120 days of filing the claim. Medicare is to be reimbursed immediately if payment is received from the pri- mary payer at a later date. Medicare as a secondary payer A clarification of the Medicare Secondary Payer (MSP) rules was published in 1996, stating that Medicare is secondary when the patient is eligible for Medicare and is also covered by one or more of the following plans: ● An employer-sponsored group health plan (EGHP) that has more than 20 covered employees.

● Disability coverage through an employer-sponsored group health plan that has more than 100 covered employees. ● An End-Stage Renal Disease case covered by an employer-sponsored group plan of any size during the first 18 months of the patient's eligibility for Medicare. ● A third-party liability policy, if the Medicare-eligible person is seeking treatment for an injury covered by such a policy (this category includes automobile insur- ance, no-fault insurance, and self-insured liability plans).

● A workers' compensation program; if the claim is contested, the provider should file a Medicare primary claim and include a copy of the workers' compensation notice declaring that the case is ""pending a Compensation Board decision."" ● Veterans Administration (VA) preauthorized services for a beneficiary who is eligible for both VA benefits and Medicare.

● Federal Black Lung Program that covers currently or formerly employed coal miners. All primary plans, which are collectively described in the Medicare literature as MSP plans, must be billed first. Medicare is billed only after the remittance advice from the primary plan or plans has been received. (The remittance advice must be attached to the Medicare claim when the claim is submitted.) Independent and hospital labs are to enter NONE in Block 11 of the CMS- 1500 claim when they bill Medicare for reference lab services when there is no face-to-face encounter with a Medicare patient.

This was changed because CMS no longer requires labs to collect Medicare secondary payer information to bill Medicare if they have had no face-to-face encounter with the patient.

Entering NONE in Block 11 will prevent claims from being denied as unprocessable. When independent or hospital labs have face-to-face encounters with Medicare patients, they must collect MSP information. To avoid fines and penalties for routinely billing Medicare as primary when it is the secondary payer, a more detailed Medicare secondary payer question- naire (Figure 14-4) should be provided to all Medicare patients when they register/reregister (update demographic and/or insurance information) with the practice.

This form is used to clarify primary and secondary insurance payers. Providers are required to collect or verify Medicare Secondary Payer (MSP) informa- tion during the initial beneficiary encounter instead of each time the patient is seen.

Providers are also encouraged to retain MSP questionnaires for at least ten years, even though five years is the required retention period. Be sure to submit a claim to Medicare for services paid by a primary payer, even if the primary payer reimbursed the entire amount charged.

Failure to submit claims to Medicare could result in patients being denied credit toward their Medicare deductible. Medicare Summary Notice The Medicare Summary Notice (MSN) (Figure 14-5) is an easy-to-read, monthly statement that clearly lists health insurance claims information. It replaced the Explanation of Medicare Benefits (EOMB), the Medicare Benefits Notice (Part A), and benefit denial letters. Billing Notes Medicare Administrative Contractor (MAC) The regional MAC for traditional Medicare claims is selected by CMS through a competitive bidding process.

Obtain the name and mailing address of the MAC for your region. Medicare Split/Shared Visit Policy The Medicare split/shared visit payment policy applies when the physician and a qualified nonphysician provider (NPP) (e.g., nurse practitioner, physi- cian assistant) each personally perform a substantive portion of a medically necessary evaluation and management (E/M) service for the same patient on the same date of service.

A substantive portion of an E/M visit involves performing all or some portion of the history, examination or medical decision making (the key components of an E/M service). The physician and qualified NPP must be in the same group practice or be employed by the same employer. Durable Medical Equipment Claims Durable medical equipment (DME) claims must be sent to one of four regional Medicare administrative contractors in the country.

Check the Medicare man- ual for the one responsible for processing DME claims for your region. Deadline for Filing Claims The claim filing deadline for both regular Medicare and Railroad Retirement claims is December 31 of the year following the date on which services were provided, unless the dates of service are between October 1 and December 31; for such claims, the deadline is extended to December 31 of the second year (after the year in which services were provided).

(The federal government's budget fiscal year begins October 1, which means that dates of service October 1 through December 31 are processed as part of the next fiscal year.) To expedite claims filing, CMS has directed MACs to apply a 10 percent penalty on any initial claim filed 13 or more months after services were performed.

Forms Used All paper claims must be submitted on the CMS-1500 claim. A minimum of 45 days should pass before an unpaid paper claim is resubmitted.

A Surgical Disclosure Notice is required for all nonassigned surgeries totaling $500 or more. A letter of medical necessity is required if the provider is to collect fees from the patient for procedures deemed by Medicare to be unreasonable, experimental, unproved, or investigational. Medicare does not differentiate between basic and major medical benefits. Medicare is not the primary payer for accidental injuries covered by any third- party liability program.

Special Handling All providers are required to file Medicare claims for their patients. Noncompliance with MSP rules and regulations may result in a substantial penalty or fine. For each filing, when Medicare is the secondary payer, a copy of the primary payer's remittance advice must be attached to the Medicare claim.

Medicaid Eligibility Medicaid policies for eligibility are complex and vary considerably, even among states of similar size and geographic proximity. Thus, a person who is eligible for Medicaid in one state may not be eligible in another state, and the services provided by one state may differ considerably in amount, duration, or scope as compared with services provided in a similar or neighboring state.

In addition, state legislatures may change Medicaid eligibility requirements during the year. Unlike Medicare, which is a nationwide entitlement program, the federal government man- dated national requirements for Medicaid and gave states the flexibility to develop eligibility rules and additional benefits if they assumed responsibility for the program's support. Medicaid provides medical and health-related services to certain individuals and families with low incomes and limited resources (the ""medically indigent"").

It is jointly funded by the federal and state governments to assist states in providing adequate medical care to qualified individuals.

Within broad federal guidelines, each state: ● ● ● ● establishes its own eligibility standards. determines the type, amount, duration, and scope of services. sets rates of payment for services. administers its own program. Thus, Medicaid varies considerably from state to state, and each state has modified its pro- gram over time. Medicaid does not provide medical assistance for all poor persons, and it is important to realize that low income is only one test for Medicaid eligibility; an individual's resources are also compared to limits established by each state in accordance with federal guidelines.

To be eligible for federal funds, states are required to provide Medicaid coverage for certain individuals who receive federally assisted income-maintenance payments and for related groups that do not receive cash payments. In addition to their Medicaid programs, most states implement ""state-only"" programs to provide medical assistance for specified poor persons who do not qualify for Medicaid.

(Federal funds are not provided for state-only programs.) The federal government provides matching funds to state Medicaid programs when certain healthcare services are provided to eligible individuals (e.g., children, disabled, seniors).

Each state administers its own Medicaid program, and CMS monitors the programs and establishes requirements for the delivery, funding, and quality of services as well as eligibil- ity criteria. Medicaid eligibility is limited to individuals who can be classified into three eligibility groups: ● ● ● Categorically needy Medically needy Special groups Categorically Needed State Medicaid programs must be available to the following mandatory Medicaid eligibility groups (or mandatory populations) because the federal government provides matching funds: ● Families who meet states' Temporary assistance for Needy Families (Ta NF) eligi- bility requirements in effect on July 16, 1996.

● Pregnant women and children under age 6 whose family income is at or below 133% of the federal poverty level (annual income guidelines established by the federal government).

● Caretakers (relatives or legal guardians who take care of children under age 18, or age 19 if still in high school) ● supplemental security Income (ss I) recipients (or, in certain states, aged, blind, and disabled people who meet more restrictive requirements than those of the ss I program). ● Individuals and couples living in medical institutions who have a monthly income up to 300% of the ss I income.

Medically Needed States that establish a medically needy Medicaid program expand eligibility to additional qualified persons who may have too much income to qualify under the categorically needy group.

(Federal matching funds are available.) This option allows: ● Individuals to ""spend down"" to Medicaid eligibility by incurring medical and/or remedial care expenses to offset their excess income. Thus, their income is reduced to a level below the maximum allowed by their state's Medicaid plan.

● Families to establish eligibility as medically needy by paying monthly premiums in an amount equal to the difference between family income (reduced by unpaid expenses, if any, incurred for medical care in previous months) and the income eligibility standard. States that implement a medically needy Medicaid program are required to include pregnant women through a 60-day postpartum period, children under age 18, certain newborns for one year, and certain protected blind persons.

States may also choose to provide coverage to other medically needy persons, including aged, blind, and/or disabled persons; caretaker relatives or legal guardians who live with and take care of children and other eligible children up to age 21 who are full-time students.

States are required to extend Medicaid eligibil- ity to all children born after September 30, 1983, who reside in families with incomes at or below the federal poverty level, until they reach age 19.

(States may choose to establish an earlier date. )Special Groups States are required to assist the following special groups: ● qualified Medicare beneficiaries (q MB) (states pay Medicare premiums, deduct- ibles and coinsurance amounts for individuals whose income is at or below 100 percent of the federal poverty level and whose resources are at or below twice the standard allowed under ss I) ● qualified working disabled individuals (q WDI) (states pay Medicare Part a premi- ums for certain disabled individuals who lose Medicare coverage because of work; these individuals have incomes below 200 percent of the federal poverty level and resources that are no more than twice the standard allowed under ss I) ● qualifying individual (q I) (states pay Medicare Part B premiums for individuals with incomes between 120 percent and 175 percent of the federal poverty level) ● specified low-income Medicare beneficiary (s LMB) (states pay Medicare Part B premiums for individuals with incomes between 100 percent and 120 percent of the federal poverty level) States may also improve access to employment, training, and placement of people with disabilities who want to work by providing expanded Medicaid eligibility to: ● Working disabled people between ages 16 and 65 who have income and resources greater than that allowed under the ss I program.

● Working individuals who become ineligible for the group described above because their medical conditions improve.

(states may require these individuals to share in the cost of their medical care.) Two additional eligibility groups are related to specific medical conditions, and states may provide coverage under their Medicaid plans: ● Time-limited eligibility for women who have breast or cervical cancer ●• Individuals diagnosed with tuberculosis (TB) who are uninsured. Women with breast or cervical cancer receive all Medicaid plan services. TB patients receive only services related to the treatment of TB.

State Children's Health Insurance Program The State Children's Health Insurance Program (SCHIP) was implemented in accordance with the Balanced Budget Act (BBA), which allows states to create or expand existing insurance programs, providing more federal funds to states for the purpose of expanding Medicaid eligibility to include a greater number of currently uninsured children.

With certain exceptions, these include low-income children who would not otherwise qualify for Medicaid. SCHIP may also be used to provide medical assistance to children during a presumptive eligibility period for Medicaid. Medicaid coverage can begin as early as the third month prior to application if the person would have been eligible for Medicaid had he or she applied during that time.

Medicaid coverage is usually discontinued at the end of the month in which a person no longer meets the criteria for any Medicaid eligi- bility group. The BBA allows states to provide 12 months of continuous Medicaid coverage (without reevaluation) for eligible children under the age of 19.

Programs of All-Inclusive Care for the Elderly (PACE) Programs of All-inclusive Care for the Elderly (PACE) use a capitated payment system to provide a comprehensive package of community-based services as an alternative to institutional care for persons age 55 or older who require a nursing facility level of care. PACE is part of the Medicare program, but is an optional ser- vice for state Medicaid plans. Thus, PACE programs operate only in states that have selected to include this option.

PACE programs enter into contracts with various types of providers, physicians, and other entities to furnish care to participants. This PACE team offers and manages all health, medical, and social services and mobilizes other services as needed to provide preventive, rehabilitative, curative, and supportive care. The care is provided in day health centers, homes, hospitals, and nursing facilities, and its purpose is to help the person maintain indepen- dence, dignity, and quality of life.

PACE providers receive payment only through the PACE agreement and must make available all items and services covered under both Medicaid and Medicare, without amount, duration, or scope limitations and without application of any deductibles, copayments, or other cost-sharing.

The individuals enrolled in PACE receive benefits solely through the PACE program. Spousal Impoverishment Protection The Medicare Catastrophic Coverage Act of 1988 (MCCA) implemented Spousal Impoverishment Protection Legislation in 1989 to prevent married couples from being required to spend down income and other liquid assets (cash and prop- erty) before one of the partners could be declared eligible for Medicaid coverage for nursing facility care.

The spouse residing at home is called the community spouse (which has nothing to do with community property). Before monthly income is used to pay nursing facility costs, a minimum monthly maintenance needs allowance (MMMNA) is deducted.

To determine whether the spouse residing in a facility meets the state's resource standard for Medicaid, a protected resource amount (PRA) is sub- tracted from the couple's combined resources.

The PRA is the greatest of the: ● ● ● ● spousal share, up to a maximum of $109,560 in 2009. state spousal resource standard, which a state could set at any amount between $21,912 and 109,560 in 2009. amount transferred to the community spouse for her or his support as directed by a court order. amount designated by a state officer to raise the community spouse's protected resources up to the minimum monthly maintenance needs standard. Confirming Medicaid Eligibility Any time patients state that they receive Medicaid, they must present a valid Medicaid identification card.

Eligibility, in many cases, will depend on the patient's monthly income. As eli- gibility may fluctuate from one month to the next, most states have a dedicated telephone line for verification of eligibility. Confirmation of eligibility should be obtained for each visit; failure to do so may result in a denial of payment.

If resid- ing in one of these states, be sure to access the Medicaid verification line. Some states have a point-of-service device similar to those used by credit card compa- nies. Beneficiaries carry plastic cards containing encoded data strips. When the card is swiped, the printout indicates eligibility or noneligibility data.

Retroactive eligibility is sometimes granted to patients whose income has fallen below the state-set eligibility level and who had high medical expenses prior to filing for Medicaid. When patients notify the practice that they have become retroactively eligible for Medicaid benefits, confirm this information before proceeding.

A refund of any payments made by the patient during the retroactive period must be made and Medicaid billed for these services. Mandatory Services 1) Services for Categorically Needy Eligibility Groups Medicaid eligibility groups classified as categorically needy are entitled to the following services unless waived under the Medicaid law.

(These service entitlements do not apply to the SCHIP programs.) ● Inpatient hospital (excluding inpatient services in institutions for mental disease). ● Outpatient hospital including Federally Qualified Health Centers (FQHCs) and if permitted under state law, rural health clinic (RHC) and other ambulatory services provided by a rural health clinic that are otherwise included under states' plans.

● ● Other laboratory and x-ray. Certified pediatric and family nurse practitioners (when licensed to practice under state law). ● Nursing facility services for beneficiaries age 21 and older. ● early and periodic screening, diagnosis, and treatment (e Psd T) for children under age 21. ● Family planning services and supplies. ● Physicians' services. ● Medical and surgical services of a dentist.

● Home health services for beneficiaries entitled to nursing facility services under the state's Medicaid plan. ● Intermittent or part-time nursing services provided by home health agency or by a registered nurse when there is no home health agency in the area. ● Home health aides. ● Medical supplies and appliances for use in the home. ● Nurse mid-wife services. ● Pregnancy-related services and service for other conditions that might complicate pregnancy. ● sixty (60) days postpartum pregnancy-related services.

Mandatory Services for medically needy eligibility groups States must provide at least the following services when the medically needy are included under the Medicaid plans: ● Prenatal and delivery services ● Post-partum pregnancy-related services for beneficiaries who are under age 18 and are entitled to institutional and ambulatory services defined in a state's plan ● Home health services to beneficiaries entitled to receive nursing facility services under the state's Medicaid plan States may provide different services to different groups of medically needy individuals, such as specified services for beneficiaries under age 21 and/or over age 65 in institutions for mental disease (IMDs); and/or intermediate care facilities for the mentally retarded (ICF/MRs), if included as medically needy.

The services provided to a particular group must also be available to everyone within that group (unless the state has obtained a waiver). Preauthorization Preauthorization is required for certain procedures and services (e.g., inpatient hospi- talizations) as mandated by state and federal law.

To be eligible for reimbursement, the provider must submit the appropriate preautho- rization form, such as California's Department of Health Care Services (DHCS) treatment autho- rization request (TAR) and/or ser- vice authorization request (SAR), to the appropriate state Medicaid field office. Once approved, the procedure or service is provided to the patient and the provider is reimbursed by Medicaid.

Mandated Preuthorization services Preauthorized Services Most states that have not placed all Medicaid beneficiaries into a prepaid HMO have some form of prior approval or preauthorization for recipients.

Preauthorization guidelines include: ● elective inpatient admission (document medical necessity justification of inpa- tient treatment and admission diagnosis and treatment plan) ● emergency inpatient admission (document medical necessity justification for inpatient treatment and admission diagnosis and treatment plan) ● More than one preoperative day (document reason [s] surgery cannot be per- formed within 24 hours of indication for surgery and specify number of additional preoperative day [s] requested) ● Outpatient procedure (s) to be performed in an inpatient setting (submit CPT code and description of surgical procedure along with medical necessity justification for performing surgery on an inpatient basis) ● days exceeding state hospital stay limitation due to complication (s) (submit diagnosis stated on original preauthorization request, beginning and ending dates originally preauthorized, statement describing the complication [s], date complication [s] presented, principal diagnosis, and complication [s] diagnosis) ● extension of inpatient days (document medical necessity justification for the extension and specify number of additional days requested)Payment for Medicaid Services Medicaid operates as a vendor-payment program, which means that states pay healthcare providers on a fee-for-service basis or states pay for Medicaid services using prepayment arrangements (e.g., an HMO).

When Medicaid makes payment directly to providers, those participating in Medicaid must accept the reimburse- ment as payment in full. States determine their own reimbursement methodol- ogy and payment rates for services, with three exceptions: (1) for institutional services, payment may not exceed amounts that would be paid under Medicare payment rates; (2) for disproportionate share hospitals (DSHs), hospitals that treat a disproportionate number of Medicaid patients, different limits apply; and (3) for hospice care services, rates cannot be lower than Medicare rates.

States can require nominal deductibles, coinsurance, or copayments for certain services performed for some Medicaid recipients.

Emergency services and family planning services are exempt from copayments. Certain Medicaid recipients are also excluded from this cost-sharing, including pregnant women, children under age 18, and hospital or nursing home patients who are expected to contribute most of their income to institutional care.

The portion of the Medicaid program paid by the federal government is known as the Federal Medical Assistance Percentage (FMAP) and is determined annu- ally for each state using a formula that compares the state's average per capita income level with the national average. Wealthier states receive a smaller share of reimbursed costs, and the federal government shares in administration expenses (minimum 50 percent match).

The federal government also reimburses states for 100 percent of the cost of services provided through facilities of the Indian Health Service, provides financial help to the 12 states that furnish the highest number of emergency services to undocumented aliens, and shares in each state's expenditures for the administration of the Medicaid program.

Most administrative costs are matched at 50 percent, although higher percentages are paid for certain activities and functions, such as development of mechanized claims processing systems. Medicare/Medicaid relationship Medicare beneficiaries with low incomes and limited resources may also receive help from the Medicaid program.

For those eligible for full Medicaid coverage, Medicare coverage is supplemented by services available under a state's Medicaid program. These additional services may include, for example, nursing facility care beyond the 100-day limit covered by Medicare, prescrip- tion drugs, eyeglasses, and hearing aids.

When an individual has both Medicare and Medicaid coverage, covered services are paid by Medicare first before any payments are made by the Medicaid program. The reason for this is because * Medicaid is always the payer of last resort. *Dual eligibles Medicare beneficiaries with low incomes and limited resources may receive help with out-of-pocket medical expenses from state Medicaid programs. Various benefits are available to dual eligibles, individuals entitled to Medicare and eligible for some type of Medicaid benefit (abbreviated as Medi-Medi).

Individuals eligible for full Medicaid coverage receive program supplements to their Medicare coverage via services and supplies available from the state's Medicaid program. Services covered by both programs are paid first by Medicare and the difference by Medicaid, up to the state's payment limit.

Medicaid also covers the following additional services: ● Nursing facility care beyond the 100-day limit covered by Medicare ● Prescription drugs ● eyeglasses ● Hearing aids Medicaid as a Secondary Payer Medicaid is always the payer of last resort.

If the patient is covered by another medical or liability policy, including Medicare, TRICARE (formerly CHAMPUS), CHAMPVA, or Indian Health Services (IHS), this coverage must be billed first. Medicaid is billed only if the other coverage denies responsibility for payment, pays less than the Medicaid fee schedule, or if Medicaid covers procedures not covered by the other policy.

Participating Providers Any provider who accepts a Medicaid patient must accept the Medicaid- determined payment as payment in full. Providers are forbidden by law to bill (balance billing) patients for Medicaid-covered benefits. A patient may be billed for any service that is not a covered benefit; however, some states have histori- cally required providers to sign formal participating Medicaid contracts.

Other states do not require contracts. Medicaid and managed care Medicaid managed care grew rapidly in the 1990s. In 1991, 2.7 million benefi- ciaries were enrolled in some form of managed care. By 2004 that number had grown to 27 million, an increase of 900 percent.

That represents 60 percent of the Medicaid population who receive benefits through managed care. States can make managed care enrollment voluntary, or they can seek a waiver of the Social Security Act from CMS to require certain populations to enroll in an MCO.

Medicaid managed care does not always mean a comprehensive healthcare plan that requires a monthly premium and is at financial risk for the cost of care provided to all enrollees. Medicaid beneficiaries are also enrolled in primary care case management (PCCM) plans, which are similar to fee-for-service plans except that each PCCM enrollee has a primary care provider who authorizes access to specialty care but is not at risk for the cost of care provided.

Most states that have not placed all Medicaid beneficiaries into a prepaid HMO have some form of prior approval or preauthorization for recipients.

Preauthorization guidelines include: ● elective inpatient admission (document medical necessity justification of inpa- tient treatment and admission diagnosis and treatment plan) ● emergency inpatient admission (document medical necessity justification for inpatient treatment and admission diagnosis and treatment plan) ● More than one preoperative day (document reason [s] surgery cannot be per- formed within 24 hours of indication for surgery and specify number of additional preoperative day [s] requested) ● Outpatient procedure (s) to be performed in an inpatient setting (submit CPT code and description of surgical procedure along with medical necessity justification for performing surgery on an inpatient basis) ● days exceeding state hospital stay limitation due to complication (s) (submit diagnosis stated on original preauthorization request, beginning and ending dates originally preauthorized, statement describing the complication [s], date complication [s] presented, principal diagnosis, and complication [s] diagnosis) ● extension of inpatient days (document medical necessity justification for the extension and specify number of additional days requested)Medicaid Eligibility Verification System The Medicaid eligibility verification system (MEVS) (sometimes called recipient eligibility verification system, or REVS) allows providers to electronically access the state's eli- gibility file using the methods listed below.

Then, a ""receipt ticket"" (Figure 15-1) is generated upon eligibility verification by MEVS. ● Point-of-service device: The patient's medical identification card contains a magnetic strip, and when the provider ""swipes"" the card through a reader, accurate eligibility information is displayed.

(The provider purchases magnetic card reader equipment.) ● Computer software: When the provider enters a Medicaid recipient's identification number into special computer software, accurate eligibility information is displayed.

● Automated voice response: Providers can call the state's Medicaid office to receive eligibility verification information through an automated voice response system. Medicaid Remittance Advice Providers receive reimbursement from Medicaid on a lump-sum basis, which means they will receive payment for several claims at once.

A Medicaid remittance advice (Figure 15-2) is sent to the provider which con- tains the current status of all claims (including adjusted and voided claims). The provider should compare content on the remittance advice to claims submitted to determine whether proper payment was received. If improper payment was issued, the provider has the option to appeal the claim. An adjusted claim has a payment correction, resulting in additional payment (s) to the provider.

A voided claim is one that Medicaid should not have originally paid, and results in a deduction from the lump-sum pay- ment made to the provider. If a year-to-date negative balance appears on the Medicaid remittance advice as a result of voided claims, the provider receives no payment until the amount of paid claims exceeds the negative balance amount. *Remittance advice documents should be main- tained according to the statute of limits of the state in which the provider practices.

Utilization Review The federal government requires states to verify the receipt of Medicaid ser- vices. Thus, a sample of Medicaid recipients is sent a monthly survey letter requesting verification of services paid the previous month on their behalf.

(Such services are identified in nontechnical terms, and confidential services are omitted.) Federal regulations also required Medicaid to establish and maintain a surveillance and utilization review subsystem (SURS), which safeguards against unnecessary or inappropriate use of Medicaid services or excess pay- ments and assesses the quality of those services. A postpayment review pro- cess monitors both the use of health services by recipients and the delivery of health services by providers.

Overpayments to providers may be recovered by the SURS unit, regardless of whether the payment error was caused by the provider or by the Medicaid program.

The SURS unit is also responsible for identifying possible fraud or abuse, and most states organize the unit under the state's Office of Attorney General, which is certified by the federal government to detect, investigate, and prosecute fraudulent practices or abuse against the Medicaid program. Medical Necessity Medical Necessity Medicaid-covered services are payable only when the service is determined by the provider to be medically necessary.

Covered services must be: ● Consistent with the patient's symptoms, diagnosis, condition, or injury. ● Recognized as the prevailing standard and consistent with generally accepted professional medical standards of the provider's peer group.

● Provided in response to a life-threatening condition; to treat pain, injury, illness, or infection; to treat a condition that could result in physical or mental disability; or to achieve a level of physical or mental function consistent with prevailing community standards for diagnosis or condition. In addition, medically necessary services are: ● Not furnished primarily for the convenience of the recipient or the provider.

● Furnished when there is no other equally effective course of treatment available or suitable for the recipient requesting the service that is more conservative or substantially less costly. Fiscal agent The name of the state's Medicaid fiscal agent will vary from state to state. Contact the local county government for information about the Medicaid pro- gram in your area. (In some states, third-party payers contract with Medicaid to process claims. )Underwriter Underwriting responsibility is shared between state and federal governments. Federal responsibility rests with CMS. The name of the state agency will vary according to state preference.

Form Used The CMS-1500 claim is required. Timely Filing Deadline Deadlines vary from state to state. Check with your State's Medicaid office. It is important to file a Medicaid fee-for-service claim as soon as possible.

The only time a claim should be delayed is when the patient does not identify Medicaid eligibility or if the patient has applied for retroactive Medicaid coverage. Medicare-Medicaid crossover claims follow the Medicare, not Medicaid, deadlines for claims. (Refer to Chapter 14 for details of the Medicare claim fil- ing deadline. )Allowable Determination The state establishes the maximum reimbursement payable for each non- managed care service.

It is expected that Medicaid programs will use the new Medicare physician fee schedule for these services, with each state establishing its own conversion factor. Medicaid recipients can be billed for any noncovered procedure performed. However, because most Medicaid patients have incomes below the poverty level, collection of fees for uncov- ered services is difficult. Accept Assignment Accept assignment must be selected on the CMS-1500 claim, or reimbursement (depending on state policy) may be denied.

It is illegal to attempt collection of the difference between the Medicaid payment and the fee the provider charged, even if the patient did not reveal Medicaid status at the time services were rendered. Deductibles A deductible may be required. In such cases, eligibility cards usually are not issued until after the stated deductible has been met.

Copayments Copayments are required for some Medicaid recipients. Inpatient Benefits All nonemergency hospitalizations must be preauthorized. If the patient's con- dition warrants an extension of the authorized inpatient days, the hospital must seek an authorization for additional inpatient days.

Major Medical/Accidental Injury Coverage There is no special treatment for major medical or accidental injury categories. Medicaid will conditionally subrogate claims when there is liability insurance to cover a person's injuries.

Subrogation is the assumption of an obligation for which another party is primarily liable. Because Medicaid eligibility is determined by income, patients can be eli- gible one month and not the next. Check eligibility status on each visit. New work requirements may change this, as beneficiaries may continue coverage for a specific time even if their income exceeds the state eligibility levels.

Prior authorization is required for many procedures and most nonemergency hospital- izations. Consult the current Medicaid handbook for a listing of the procedures that must have prior authorization. When in doubt, contact the state agency for clarification. Cards may be issued for the ""Unborn child of .

. ."" (the name of the pregnant woman is inserted in the blank space). These cards are good only for services that promote the life and good health of the unborn child.

Because other health and liability programs are primary to Medicaid, the remittance advice from the primary coverage must be attached to the Medicaid claim. A combined Medicare-Medicaid (Medi-Medi) claim should be filed by the Medicaid deadline on the CMS-1500 claim. Before working with Medicaid claims, complete the Review located at the end of this chapter. Mother/baby claim A mother/baby claim is submitted for services provided to a baby under the mother's Medicaid identification number. (The mother's services are not reim- bursed on the mother/baby claim; they are submitted on a separate CMS-1500 claim according to the instructions in Table 15-1.

)Tricare TRICARE is a healthcare program for (1) active duty members of the military and their quali- fied family members, (2) CHAMPUS-eligible retirees and their qualified family members, and (3) eligible survivors of members of the uniformed services.

CHAMPUS (now called TRICARE Standard) is an abbreviation for the Civilian Health and Medical Program of the Uniformed Services, a federal program created in 1966 (and implemented in 1967) as a benefit for depen- dents of personnel serving in the uniformed services (U. S. military branches that include the Army, Navy, Air Force, Marines, and Coast Guard), Public Health Service, and the National Oceanic and Atmospheric Administration (NOAA). TRICARE was created to expand health- care access, ensure quality of care, control healthcare costs, and improve medical readiness.

CHAMPUS (now called TRICARE) was implemented in 1967 as the result of an initiative to provide military medical care for families of active-duty mem- bers. The original budget was $106 million; the current budget is more than $24 billion (2002 Tricare Stakeholders' Report, volume IV).

In the 1980s the Department of Defense (Do D) began researching ways to improve access to quality care while controlling costs, and demonstration projects were autho- rized. One demonstration project, the CHAMPUS Reform Initiative (CRI) carried out in California and Hawaii, offered military families a choice of how their health- care benefits could be used.

The Do D noted the successful operation and high levels of patient satisfaction associated with the CRI, and it was determined that its concepts should be expanded to a nationwide uniform program.

** Used to be 12 regions; NOW there are 4 (3 U. S., 1 international)Tricare management This new program became known as TRICARE, a regionally-managed health- care program that joins the healthcare resources of the uniformed services (e.g., Army) and supplements them with networks of civilian healthcare profession- als to provide access and high-quality service while maintaining the capability to support military operations.

TRICARE is a healthcare program for active-duty members of the uniformed services and their families, retirees and their fami- lies, and survivors of all uniformed services who are not eligible for Medicare.

There are four TRICARE regions: three in the United States and TRICARE overseas (Figure 16-1). Each is managed by a Lead Agent staff that is responsible for the military health system in that region. Commanders of selected military treatment facilities (MTFs) are selected as lead agents (LA) for the TRICARE regions.

The Lead Agent staff serves as a federal healthcare team created to work with regional military treatment facility commanders, uniformed service headquarters' staffs, and Health Affairs (HA) to support the mission of the Military Health Services System (MHSS). The Military Health Services System (MHSS) is the entire healthcare system of the U. S. uniformed services and includes MTFs as well as various programs in the civilian healthcare market, such as TRICARE. Health Affairs (HA) refers to the Office of the Assistant Secretary of Defense for Health Affairs, which is responsible for both military readiness and peacetime health care. Stepchildren lose eligibility after a divorce unless they are adopted by the sponsor. Tricare Administration The TRICARE Management Activity (TMA) (formerly called OCHAMPUS) is the office that coordinates and administers the TRICARE program and is accountable for quality health care provided to members of the uniformed services and their families. The TMA also serves as arbitrator for denied claims submitted for consideration by TRICARE sponsors and beneficiaries; its offices are located in Aurora, Colorado. TRICARE sponsors are uniformed service personnel who are either active duty, retired, or deceased. (Dependents of deceased sponsors are eligible for TRICARE benefits.) Sponsor information (e.g., SSN, DOB, and last name) can be verified in the Defense Enrollment Eligibility Reporting System (DEERS), a computer system that contains up-to-date Defense Department workforce personnel information. TRICARE beneficiaries include sponsors and dependents of sponsors. TRICARE Service Centers cont. below TRICARE regions are served by one or more TRICARE Service Centers (TSC), business offices staffed by one or more beneficiary services representatives and health- care finders who assist TRICARE sponsors with healthcare needs and answer questions about the program. See more "

Home health care can be covered under either Medicare Part A or Part B. There are no deductibles or coinsurance associated with home health care except for durable medical equipment in which case Medicare will pay 80 percent and the patient or other insurance will pay the remaining 20 percent.

Previous Next Understanding Medicare Part B Deductible QUESTION: At the start of each year I get confused about the Medicare Part B deductible. I have several doctors and never know which one I should pay. Can you provide a simple explanation?

ANSWER: The key to understanding the puzzle can be found in your Medicare Summary Notice (MSN). The Medicare Part B deductible is applied on a basis of first claim received, first claim applied to the deductible. This means that when the new year starts Medicare will apply your first claim or claims received to your deductible until the full deductible has been satisfied. Keep in mind that the first claim Medicare receives may or may not necessarily be from the first doctor you saw in the New Year.

Your summary notice will show which provider’s services Medicare applied to the deductible, the amount of the deductible owed to that provider and how much of the deductible has been met for the year. You will receive a bill from the provider for the amount owed. Once the deductible has been fully satisfied the subsequent summaries will indicate your deductible has been met for the year and Medicare will start to pay its portion of new claims as they come in.

Your provider may request the deductible amount at the time of your visit but because the status of your deductible may not be known at the time of your appointment, I suggest you wait until you receive your summary notice before paying anything.

Better still wait for a bill from your doctor before you pay the amount – and the amount billed should be the same as the amount shown on the summary notice.

QUESTION: A neighbor recently returned home from the hospital and needed in-home assistance. I was told she had to pay for those services. Doesn’t Medicare pay for in-home care? ANSWER: In-home care is a complex subject and you are not alone in your thinking.

Medicare pays only for “medically necessary” services and does not pay for “custodial” care. Custodial care essentially covers assistance with meeting activities of daily living. It includes help with walking, getting into and out of bed, bathing, dressing, eating and going to the toilet.

It could include preparation of special diets and supervision of taking self-administrated medication. It does not require the services of trained medical or paramedical personnel. In contrast home health care is skilled nursing care and certain other services received in the home for treatment of an illness or injury. Medicare covers this care in the home if the patient meets eligibility requirements. To qualify for home health care the patient must have a doctor order and present a plan for such care.

The plan must show that either intermittent – not full-time – skilled nursing care or physical, speech or occupational therapy is required. The patient must be homebound. This means the patient normally cannot leave home and that leaving home is a major effort. A patient who leaves home must do so rarely and only for a short period of time. Last – the home health agency caring for the patient must be approved by the Medicare program and bill Medicare directly for their services.

HAPPENINGS: TUESDAY – January 19 – 5:30 to 7:00 pm – Presentation – “Urber Assist – Uber WAV” (wheelchair accessible vans) – expanding transportation options in the area – at Senior Concerns Day Care Center, 401 Hodencamp Road in Thousand Oaks.

For reservations call (805) 497-0189. WEDNESDAY – January 20 – 9:00 am to 1:00 pm – 2 nd Annual Wellness Fest – at Goebel Adult Community Center, 1385 E. Janss Road in Thousand Oaks.

A day to meet Senior Service Providers – check out all your wellness needs under one roof. By Betty Berry | January 6th, 2016 | Betty Berry's Column, Information | 0 Comments Share This Story, Choose Your Platform!About the Author: Betty Berry Betty Berry brings a deep understanding of senior issues to her position as Senior Advocate for Senior Concerns.

She has advocated for seniors since 1993. Through the Health Insurance Counseling Advocacy Program, known as HICAP, she is registered with the State of California as an Insurance Counselor, a Long-Term Care Insurance Counselor and a Community Educator.

She has served on the Area Agency on Aging’s Advisory Council as a member and Chair, has been a member of the Financial Abuse Strategic Team (FAST) and currently serves on the Conejo Senior Volunteer Program (CSVP) Advisory Board and authors the Senior Advocate column that appears in the Ventura County Star.

Betty completed her undergraduate degree at California Lutheran University and earned her Juris Doctorate degree at Ventura College of Law. Related Posts Permalink Holidays, a good time to look for signs of elder abuse Permalink Good advice for seniors: Don’t worry, be happy Permalink New Medicare cards safer to carry Permalink Experience shape seniors’ moral compass Permalink Social Security offers online account

The challenge: Ophthalmologists often describe durable medical equipment (DME) coding and billing as one of the most complex duties they perform. Coding for refractive lenses makes it even more complex, with the multitude of options available to patients combined with Medicare's strict coverage guidelines.

Look to Modifiers KX, EY for Keys to DME Reimbursement

"Look to Modifiers KX, EY for Keys to DME Reimbursement- Published on Mon, Nov 03, 2008Keep medical necessity distinct from patient preference in documentation. If you're providing refractive lenses for cataract surgery patients, you'll need to unravel your DME MAC's complex coding and billing rules to claim deserved Medicare reimbursement.

Medicare will only pay for refractive lenses for aphakic beneficiaries (patients who are lacking the organic lens of the eye due to surgical removal, e.g., after cataract surgery, or who have congenital absence). Medicare covers one complete pair of glasses or contact lenses after each cataract surgery with insertion of an artificial intraocular lens, notes Joyce D. Ardrey, CPC, who led a seminar on billing for frames, lenses, and contact lenses at The Coding Institute's 2008 Optometry & Ophthalmology Coding and Reimbursement Conference.

Most DME Medicare Administrative Contractors (DME MACs) specify that your claim for refractive lenses must be linked to one of these ICD-9 codes to prove medical necessity:• 379.31 -- Aphakia• 743.35 -- Congenital aphakia • V43.1 -- Organ or tissue replaced by other means; lens (pseudophakia). Append KX for Doctor-Ordered Extras The key to DME MAC reimbursement for refractive lens features is medical necessity, and this involves more than just choosing the right ICD-9 code.

The standard benefit is a flat-top (FT) 25/28 bifocal or trifocal in plastic or glass, explains David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas. If the patient or the doctor want more features, a modifier will be necessary on the claim. The prescribing physician must specifically order the special lens; it cannot be the patient's preference for one type of lens over another. If a physician specifically orders a particular type of lens or lens treatment, append modifier KX (Specific required documentation on file) to the HCPCS code.

This modifier tells Medicare that you have documentation to support the medical necessity of the item you're claiming. Example: In most cases, Medicare will not pay for polycarbonate lenses (V2784). Patients often prefer polycarbonate lenses because they are sturdier and lighter than regular lenses. However, many ophthalmologists prescribe polycarbonate lenses for patients with monocular vision to help protect the remaining eye.

In these cases, report the lens with modifier KX (V2784-KX) and make sure documentation of the patient's condition is on file. For example, a note in the patient's record saying, ""best corrected VA OS 20/400"" should suffice.

""It doesn't need to go on the claim; just have it in the records,"" says Gibson. Additionally, Medicare considers ultraviolet protection (V2755, U-V lens, per lens) reasonable and necessary after a cataract extraction. [...]SIGN UP / LOGIN to read the article. "

Durable Medical Equipment (DME): Medical equipment that is ordered by a provider for patient use outside of the facility which can withstand repeated use, is not disposable, is used to serve a medical purpose and is appropriate for the home. Effective Date: See Eligibility Date.

Glossary of Billing Terms

"Glossary of Billing Terms The following is a list of frequently used billing and insurance terms as defined by Centers for Medicare and Medicaid Services (CMS). Please do not hesitate to contact a billing representative with questions about your bill. Accessibility of Services: The ability to get medical care and services when they are needed.

Account Number: The tracking number assigned within Children's Surgical Specialty Group to identify the patient, the guarantor (person legally responsible for payment on the account) and the patient's date (s) of service (s). This account number will remain the same even if the patient is seen by a different physician and or specialty within the group.

If the patient turns 18 a new account number may be given. Addressee: The name and address of the guarantor (a guarantor is the person legally responsible for payment on the account).

Advance Beneficiary Notice (ABN): A notice that a provider or facility should give a plan beneficiary to sign in the following cases: Your doctor gives you a service that he or she believes that the plan may not consider medically necessary; and your doctor gives you a service that they believe the plan will not pay for.

The ABN may also be referred to as a waiver. Affiliated Provider: A health care provider or facility that is contracted and paid by a health plan to give service to plan members. Allowed Charge: Contracted rate for individual charges determined by a carrier for a covered medical service or supply.

Ambulatory Care: All types of health services that do not require an overnight hospital stay. Ambulatory Surgical Center: A facility other than a hospital that performs outpatient surgery. Appeal Process: The process you use if you disagree with any decision about the health care process, service or payment. If the participant is in a managed care plan, they can file an appeal if the plan will not pay for, does not allow or stops a service that the patient or provider believes should be covered or provided.

The plan may have special protocols to follow in order to file an appeal. See the plan's membership materials or contact the plan for details about appeal rights and procedures. Approved Amount: The negotiated amount established in the agreement between the provider and plan to cover a particular service.

Assignment: A process whereby a plan or payor pays its share of the allowed charge directly to the physician or supplier. Beneficiary: The person who is eligible to receive benefits through a health insurance program. Benefits: The money or services provided and covered under an insurance policy. Board Certified: This means a doctor has special training in a certain area of medicine and has passed an advanced exam in that area of medicine.

Both primary care doctors and specialists may be board-certified. Capitation: A provider payment method used by health plans.

The provider is paid a set amount per member per month. The provider receives the same amount regardless of how many times the member uses his or her services. Carrier: An entity that may underwrite or administer a range of health benefit programs. May refer to an insurer or a managed health plan.

Cash Basis: The actual charge of the service when the service was performed. Centers for Medicare and Medicaid Services (CMS): The federal agency that runs the Medicare program. In addition, CMS works with the States to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

Claim: A claim is a request for payment for services and benefits received. Information is customarily submitted by a provider to establish that medical services were provided to a covered person.

CMS-1500: The uniform professional claim form. Coinsurance: The co-payment a member makes based on a percentage of the costs of the medical services received, usually around 10 to 20 percent. Coinsurance is usually found in indemnity, fee-for-service and PPO plans, often along with deductibles.

Confidentiality: The ability to speak with the provider or representative without disclosing the information to an uninterested party. Consolidated Omnibus Budget Reconciliation Act (COBRA): A federal law permitting many people who lose eligibility under a group health plan to continue that coverage without a lapse.

Coordination of Benefits: A process that applies when determining which plan or insurance policy will pay first if multiple policies exist. Copayment: The set amount, usually $5 to $25, an HMO member pays the provider for services. Unlike coinsurance, this amount is not based on a percentage of the actual cost of services, but is pre-determined.

Covered Charges: Services or benefits for which a health plan makes either partial or full payment. Covered Entity: Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Deductible: The annual amount payable by the beneficiary for covered services before Medicare makes reimbursement. Deductible (Medicare): The dollar amount that a member must pay for medical services before health plan coverage begins. Demographic Data: Data that describe the characteristics of the beneficiary and/or guarantor. Demographic data include but are not limited to age, sex, race/ethnicity, and primary language.

Department of Health and Human Services (DHHS): DHHS administers many of the ""social"" programs at the Federal level dealing with the health and welfare of the citizens of the United States.

It is the ""parent"" of CMS. Determination: A decision made to either pay in full, pay in part, or deny a claim. Diagnosis: The name for the health problem the patient presented with or was treated for during an encounter or communication with the provider. Diagnosis Code: ICD-9-CM diagnosis code sets that correspond to conditions that (co)existed at the time of treatment. Disclosure: Release or divulgence of information by an entity to persons or organizations outside of that entity. Disenroll: Ending health care coverage with a health plan.

Durable Medical Equipment (DME): Medical equipment that is ordered by a provider for patient use outside of the facility which can withstand repeated use, is not disposable, is used to serve a medical purpose and is appropriate for the home. Effective Date: See Eligibility Date.

Eligibility: Refers to the process whereby an individual is determined to be eligible for health care coverage through their plan. Eligibility Date: The date on which health plan coverage begins. Enroll: To join a health plan. Explanation of Benefits: A coverage statement that is sent to the patient and/or provider when a claim is filed.

The statements informs what the provider billed for, the plan's approved amount and how much they paid. Fee Schedule: A comprehensive list of all services provided and their respective charge. Fee-for-Services: A method of paying the provider for service or treatment based on the fee schedule.

Formulary: A list of certain drugs and their proper dosages. In some health plans, doctors must order or use only drugs listed on the health plan's formulary. Gatekeeper: In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.

Grievance: A complaint about the way health care service, process or payment were handled. Guarantor: The person responsible for payment of rendered services.

The guarantor is customarily the person bringing the patient in for treatment. This person is not necessarily the same as the subscriber. Health Care Provider: A person who is trained and licensed to give health care. Also, a place licensed to give health care.

Doctors, nurses, hospitals, skilled nursing facilities, some assisted living facilities, and certain kinds of home health agencies are examples of health care providers. Health Insurance Portability and Accountability Act (HIPAA): HIPAA is the Health Insurance Portability and Accountability Act signed into law in 1996.

An Administrative Simplification section in the law requires adoption of standards for security, privacy and electronic healthcare transactions. Health Maintenance Organization (HMO): A legal corporation that provides health care in return for pre-set monthly payments. For most HMOs, members must use the physicians, hospitals and other health care professionals in the HMO's network in order to be covered for their care.

There are several models of HMO, including the Staff Model, Group Model, IPA Model, Direct Contract Model and Mixed Model. Health Plan: An entity that assumes the risk of paying for medical treatments, i.e. uninsured patient, self-insured employer, payer, or HMO. Indemnity: This is a form of coverage offered by most traditional insurers. An indemnity plan reimburses the patient directly medical costs regardless of who provided them.

Insurer: An insurer of a Group Health Plan (GHP) is an entity that, in exchange for payment of a premium, agrees to pay for GHP-covered services received by eligible individuals. Interest: A payment for the use of money during a specified period. May also be a form of penalty for non-timely reimbursement.

Letter of Request: A formal request from the requestor detailing informational needs and purposes. Managed Care: A term originally coined to refer to the prepaid health care sector (e.g., HMOs) where care is provided under a fixed budget and costs are supposedly capable of being ""managed.""

Now the term also can refer to PPOs and some forms of indemnity insurance coverage that incorporate preadmission certification and other utilization controls. Managed Care Organization (MCO): A health plan that provides coordinated health care through a network of primary care physicians and hospitals for pre-set monthly payments. Medicaid: A health plan that provides coordinated health care through a network of primary care physicians and hospitals for pre-set monthly payments.

A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. Medicaid MCO: A Medicaid MCO provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

Medically Necessary: Services or supplies that are proper and needed for the diagnosis or treatment of your medical condition; are provided for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local area; and are not mainly for the convenience of the patient or provider. Medigap Policy: A Medicare supplemental insurance policy sold by private insurance companies to fill ""gaps"" in Original Medicare Plan coverage.

Member: See Subscriber. Military Treatment Facility: A medical facility operated by one or more of the Uniformed Services. National Committee for Quality Assurance (NCQA): A non-profit organization that accredits and measures the quality of care in health plans. NCQA does this by using the Health Employer Data and Information Set (HEDIS) data reporting system. Network: A group of health care providers and suppliers of other goods and services to provide service to patients.

Non-covered Service: The service (a) does not meet the requirements of a benefit and (b) may not be considered reasonable and necessary. Non-participating Physician: A provider that is not contracted or accepts assignment with a particular plan. Nurse Practitioner: A nurse who has advanced training and assists physicians by providing care to patients in their absence.

Must stay within the scope of their abilities. NPs may also be considered providers. Office: Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

Open Access: A term describing a member's ability to self-refer for specialty care. These models allow patients to see a participating specialist without a referral. Out of Network: Services a member receives from a health care provider who does not belong to the member's health plan's network of selected and approved physicians and hospitals.

If the services were not pre-approved by the health plan, the member may have to pay for all or most of that care him/herself.

Exceptions are usually made for extreme emergencies or urgent care needed when traveling away from home. Out of Pocket Costs: Health care expenses that the patient is responsible for as they are not fully or partially covered by their plan. Outpatient Care: Medical or surgical care that does not include an overnight hospital stay. Participating Physician or Supplier: A provider who agrees to accept assignment on the claims.

These providers should only initially bill for the patient's cost share amount. Payer: In health care, an entity that assumes the risk of paying for medical treatments. This can be an uninsured patient, a self-insured employer, a health plan, or an HMO. Point of Service (POS): A health plan option that allows members to use either a network provider or a non-network provider at their discretion.

If a member chooses to go out of network, they may pay a higher co-pay or deductible. Pre-existing Condition (Medigap Policy): A medical condition the patient had before the date that a new insurance policy starts.

Preferred Provider Organization (PPO): A network of doctors and hospitals that provide health care services at a pre-negotiated lower price. Members receive better benefits when they use network providers, but have the option to use out-of-network providers for higher out-of-pocket costs. Premium: The predetermined monthly membership fee a subscriber or employer pays for health plan coverage.

Preventive Care: Care designated to keep the patient healthy or to prevent illness, such as colorectal cancer screening, yearly mammograms, and flu shots. Primary Care: A basic level of care usually given by doctors who work with general and family medicine, internal medicine (internists), pregnant women (obstetricians), and children (pediatricians). A nurse practitioner (NP), a state-licensed registered nurse with special training, can also provide this basic level of health care.

Primary Payer: An insurance policy, plan, or program that pays first on a claim for medical care. Procedure: Something done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures. Protected Health Information (PHI): Individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate.

Identifies the individual or offers a reasonable basis for identification. Is created or received by a covered entity or an employer. Relates to a past, present, or future physical or mental condition, provision of health care or payment for health care. Provider: Any healthcare provider such as hospital, physician, non-physician provider, laboratory, etc.

that provides medical services. Referral: The formal process that gives a health plan member authorization to receive care from a provider other than his or her primary care provider.

Without a referral, such care may not be covered. Referral Authorization: The verbal or written approval of a referral request that gives a health plan member authorization to receive care from a provider outside the plans established network. Referral Physician: The physician a patient has been referred to by his or her primary care provider. Secondary Payer: An insurance policy that supplements the primary coverage and pays second on a claim for medical care.

Service Area: The geographic area serviced by the health plan as approved by the state regulatory agencies and/or detailed in the certification of authority.

Specialist: A doctor who treats only certain parts of the body, certain health problems, or certain age groups. Subscriber: A participant in a health plan (enrollee or eligible dependent) who makes up the plan's enrollment. Also used to describe an individual specified within the policy who may or may not receive services according to the benefit limits. Termination Date: The date that an agreement expires or the date that a subscriber and/or member ceases to be eligible.

Third Party Administrator (TPA): An organization that administers health care benefits-including claims review, claims processing, etc.-usually for self-insured employers. Transaction: The exchange of information between two parties to carry out financial or administrative activity.

TRICARE: TRICARE is the health care program for active duty members of the military, military retirees, and their eligible dependents. TRICARE was called CHAMPUS in the past. Urgently Needed Care: Care sought after or received for a sudden illness or injury that needs medical care right away, but is not life-threatening. Utilization Summary Data: Data that are aggregated by the capitated managed care entity (e.g. the number of primary care visits provided by the plan during the calendar year).

Withhold: A financial incentive used to encourage efficient care. It is the portion of the monthly capitation payment that is withheld if the physician exceeds utilization norm. "

Aetna considers prothrombin time home testing units/home INR testing (e.g., the Coag-Sense Self-Test PT/INR Monitoring System, the Coagu Chek XS Plus System, and the INRatio® 2 PT/INR Monitoring System) medically necessary durable medical equipment for persons who require chronic oral anticoagulation with warfarin for a mechanical heart valve, ven

Prothrombin Time (INR) Home Testing Devices

"Number: 0173Policy

tricular assist device, chronic atrial fibrillation, deep venous thrombosis, pulmonary embolism, venous embolism and thrombosis of deep vessels of lower extremity, or hypercoagulable states (e.g., antithrombin III deficiency, Factor V Leiden, protein C deficiency, and protein S deficiency, etc) when all of the following criteria are met: The expected need for home INR testing is 6 or more months; and The person must have been anticoagulated for at least 3 months prior to use of the home INR devices; and Self-testing with the device should not occur more frequently than once a week.

Aetna considers prothrombin time home testing units experimental and investigational for all other indications (e.g., arterial embolism to the eye, atrial flutter, and Kawasaki disease) because its effectiveness for indications other than the ones listed above has not been established.

Aetna considers additional hardware/software systems needed for down-loading data from prothrombin time home testing units to computers for the management of anticoagulation as not medically necessary convenience items.

Background This policy is consistent with the conclusions of an assessment from the Centers for Medicare & Medicaid Services (CMS, 2008). Prothrombin time home testing systems are portable, battery-operated instruments for the quantitative determination of prothrombin time from finger-stick whole blood. The monitoring device measures the time it takes an individual’s blood to clot. A drop of blood is obtained by a finger-stick using a lancet.

The drop of blood is placed on a test strip and analyzed by the device. The device displays both the PT and calculated international normalized ratio (INR). If the results are out of normal range, the individual usually is advised to retest to confirm and if the results remain abnormal, they contact their physician as soon as possible. These devices store 30 - 60 of the most recent test results, which are date and time stamped, enabling the health care provider to review the results and monitor trends in the individual’s oral anticoagulant therapy control.

The goal of home PT monitoring is to help the individual maintain an INR in the desired therapeutic range.

International Normalized Ratio (INR) is a system established by the World Health Organization (WHO) and the International Committee on Thrombosis and Hemostasis for reporting the results of blood coagulation (clotting) tests. The INR is the ratio of the individual's prothrombin time compared to the mean prothrombin time for a group of normal individuals.

The prothrombin time is the amount of time needed for a small amount of blood to clot. Examples of US Food and Drug Administration (FDA) approved devices for home self-monitoring PT/INR include, but may not be limited to: Alere INRatio 2 PT/INR Monitoring System; Coag Care System; Coagu Chek XS System; INRatio Prothrombin Time Monitoring System; INRatio 2 Prothrombin Time Monitoring System; and Pro Time Microcoagulation System.

These portable testing devices are available by prescription for home use under a physician’s supervision. The physician who prescribes a home PT monitor is responsible for the training and ongoing management of individuals who use these devices. Alternatives to home PT monitoring include visits to a laboratory facility or health care provider’s office for drawing and testing of a venous blood sample. Physician consultation is advised to make an informed decision based on an individual’s health needs.

Home INR monitors are designed to aid in the management of high-risk patients taking oral anticoagulants.

They require considerable patient training and compliance to be useful. Self-testing and/or self-management by the patient using home international normalization ratio (INR) monitors represent another model of care with the potential for improved outcomes as well as greater convenience. Self-testing may provide a convenient opportunity for increased frequency of testing when deemed necessary. The use of the same instrument may increase the degree of consistency in instrumentation, and self-testing provides the potential for greater knowledge and awareness of therapy which may lead to improved compliance.

There is, however, insufficient evidence comparing the effectiveness of patient self-testing and self-management using a home INR monitor to care provided by an anticoagulation management service.

Ansell et al (2001) explained: ""Although a growing number of studies indicate the superiority of patient PST [patient self-testing] or PSM [patient self-management of dose adjustments] over UC [usual care, i.e., patients managed by their usual physicians], there is little evidence comparing them to care provided by an AMS [anticoagulation management service (i.e., anticoagulation clinic)]. PST and PSM require special patient training to implement, and therapy should be managed by a knowledgeable provider.

A definitive recommendation cannot yet be made as to the overall value of PST or PSM. ""In a randomized controlled trial, Gardiner and colleagues (2005) ascertained if patients can achieve accurate INR values through patient self testing (PST) by means of the Coagu Chek S (Roche Diagnostics, Lewes, UK). The main outcome measurements were comparability of INR values obtained by PST and the hospital laboratory, patient acceptability as assessed by a questionnaire and anticoagulant control.

A total of 84 subjects (53 men, 31 women; median age of 59 years), receiving long-term oral anticoagulation (warfarin), were recruited. Subjects were randomized to weekly self-testing or continuing 4-weekly hospital laboratory monitoring of INR. Comparison of INRs (n = 234) showed no significant differences between the Coagu Chek (median INR 3.02) and laboratory testing (median INR 3.07).

There was excellent correlation between the 2 methods (r = 0.95), with 85 % of Coagu Chek results within 0.5 INR units of the laboratory method.

On 4 occasions, differences of greater than 1 unit INR were obtained, but in each case the patient's anticoagulation was unstable (INR greater than 4.5 by both methods) and the differences in INR would not have altered patient management. The results showed that 87 % of patients found self-testing straightforward, 87 % were confident in the result they obtained and 77 % preferred self-testing.

These investigators concluded that PST is a reliable alternative to hospital clinic attendance and is acceptable to the majority of suitably trained patients. In 2002, CMS issued a national coverage determination for the use of home prothrombin time INR monitoring for anticoagulation management for patients with mechanical heart valves on warfarin.

More recently, a CMS Decision Memorandum (2008) concluded that there is sufficient evidence of the effectiveness of home prothrombin time (INR) monitoring for patients with a mechanical heart valve, chronic atrial fibrillation, or deep venous thrombosis.

The monitor and the home testing must be prescribed by a treating physician and the following requirements must be met: Self-testing with the device should not occur more frequently than once a week; and The patient continues to correctly use the device in the context of the management of the anticoagualtion therapy following initiation of home monitoring; and The patient must have been anticoagulated for at least 3 months prior to use of the home INR devices; and The patient must undergo an educational program on anticoagulation management and demonstrated the correct use of the device prior to its use in the home.

Matchar and colleagues (2010) examined the effect of home testing of INR on clinical events in patients with atrial fibrillation or mechanical heart valves. These investigators randomly assigned 2,922 patients who were taking warfarin because of mechanical heart valves or atrial fibrillation and who were competent in the use of point-of-care INR devices to either weekly self-testing at home or monthly high-quality testing in a clinic.

The primary end point was the time to a first major event (stroke, major bleeding episode, or death).

Patients were followed for 2.0 to 4.75 years, for a total of 8,730 patient-years of follow-up. The time to the first primary event was not significantly longer in the self-testing group than in the clinic-testing group (hazard ratio, 0.88; 95 % confidence interval [CI]: 0.75 to 1.04; p = 0.14).

The 2 groups had similar rates of clinical outcomes except that the self-testing group reported more minor bleeding episodes. Over the entire follow-up period, the self-testing group had a small but significant improvement in the percentage of time during which the INR was within the target range (absolute difference between groups, 3.8 percentage points; p < 0.001).

At 2 years of follow-up, the self-testing group also had a small but significant improvement in patient satisfaction with anti-coagulation therapy (p = 0.002) and quality of life (p < 0.001). The authors concluded that as compared with monthly high-quality clinic testing, weekly self-testing did not delay the time to a first stroke, major bleeding episode, or death to the extent suggested by prior studies.

These results do not support the superiority of self-testing over clinic testing in reducing the risk of stroke, major bleeding episode, and death among patients taking warfarin therapy.

Bonaros et al (2004) stated that ventricular assist device (VAD) implantation is associated with impaired primary hemostasis and thromboembolic complications. Recently, a new generation of implantable continuous flow axial pumps was introduced into clinical application. To study the potential thrombogenic properties of this type of pump, these researchers applied extensive platelet monitoring.

In their institution, 13 patients received the Micro Med De Bakey VAD as a bridge to transplantation. Routine coagulation tests (platelet count, activated partial thromboplastin time, prothrombin time, anti-thrombin III activity) and platelet function tests (whole blood aggregometry, thrombelastography, flow cytometry) were performed. No clinically relevant thromboembolic events were detected. No correlation was found between global function tests, platelet aggregation, and thrombelastography.

No correlation was detected between platelet activation and hemolysis parameters. Platelet aggregation and coagulation index were significantly suppressed early after operation. A subsequent phase of hyper-aggregability, starting around day 6, suggested the initiation of anti-aggregation therapy.

Platelet activation markers were up-regulated in the post-operative period but were returned to pre-operative levels after initiation of aspirin. In contrast to routine coagulation monitoring, platelet function tests reflect in detail the coagulation status of blood pump recipients and the efficiency of anti-aggregation therapy.

Aspirin and dipyridamole therapy in addition to oral anti-coagulation using phenprocoumon may contribute to platelet function and clot mechanics restoration and is, therefore, recommended for patients after VAD implantation. Joshi and colleagues (2007) noted that prothrombin time, expressed as INR and activated partial thromboplastin time (a PTT), are standard methods of monitoring coumadin and heparin administration. Prothrombin activation fragment (F1.2) is an index of in vivo thrombin generation. These investigators hypothesized that F1.2 would provide a better surrogate of thromboembolism risk than standard coagulation assays during VAD support.

In this study, INR, PTT and F1.2 were analyzed in 31 patients after implantation of a left-sided VAD daily during hospitalization and weekly after discharge. Thromboembolic events (TE) were defined by evidence of neurological injury revealed by plasma levels of S-100beta. The relationships between F1.2, INR for patients on coumadin and a PTT for patients on heparin were evaluated from 1,250 observations of blood samples. S-100beta was positively correlated with F1.2, but not with INR and a PTT. Correlation between S-100beta and F1.2 is significantly higher than with the other 2 markers (p < 0.0001). Higher values of a PTT and INR were not associated with TE. Compared to conventional coagulation assays, the F1.2 level provides a single endpoint that is a more accurate predictor of TE after VAD implantation.

The authors stated that further trials that incorporate the F1.2 marker into anti-coagulation algorithms may help reduce adverse events in this high-risk population. CPT Codes / HCPCS Codes / ICD-10 Codes Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by ""+"": Information in the [brackets] below has been added for clarification purposes.

Codes requiring a 7th character are represented by ""+"": Code Code Description CPT codes covered if selection criteria are met:93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face- to- face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test (s), when performed HCPCS codes covered if selection criteria are met: G0248 Demonstration, prior to initial use, of home INR monitoring for patient with either mechanical heart valve (s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face- to- face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing prior to its use G0249 Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve (s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; not occurring more frequently than once a week G0250 Physician review, interpretation and patient management of home INR testing for a patient with either mechanical heart valve (s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes face- to- face verification by the physician that the patient uses the device in the context of the management of the anticoagulation therapy following initiation of the home INR monitoring; not occurring more frequently than once a week ICD- 10 codes covered if selection criteria are met: D68.51 - D68.62 Thrombophilia (Antithrombin III deficiency, Factor V leiden, Protein C deficiency, Protein S deficiency)I26.01 - I26.99 Pulmonary embolism I27.82 Chronic pulmonary embolism I48.0, I48.2,I48.91Atrial fibrillation I80.00 - I80.9 Phlebitis and thrombophlebitis of upper and lower extremities and unspecified site T80.0XX+,T81.718+,T81.72X+T82.817+ - M82.818+ [I26.90,I26.99 also required]Pulmonary embolism and infarction Z95.2 Presence of prosthetic heart valve Z95.811 Presence of heart assist device ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): H34.9 Unspecified retinal vascular occlusion [arterial embolism to the eye]I48.1 Atrial flutter M30.3 Mucocutaneous lymph node syndrome [Kawasaki disease]The above policy is based on the following references: No authors listed.

Home monitoring for warfarin users. Health News. 1999;5 (3):5. No authors listed. A new approach to monitoring anticoagulation therapy: Testing prothrombin time at home.

Harv Heart Lett. 1999;9 (5):2-4. Ansell J, Hirsh J, Dalen J, et al. Managing oral anticoagulant therapy. In: Sixth ACCP Conference on Antithrombotic Therapy. Chest. 2001;119:22S-38S. Poller L, Keown M, Chauhan N, et al. European Concerted Action on Anticoagulation--comparison of fresh plasma and whole blood multicentre ISI calibrations of Coagu Chek Mini and TAS PT-NC whole blood prothrombin time point-of-care monitors.

Thromb Haemost. 2002;87 (5):859-866. Nowatzke WL, Landt M, Smith C, Wilhite T, et al. Whole blood international normalization ratio measurements in children using near-patient monitors. J Pediatr Hematol Oncol. 2003;25 (1):33-37. Center for Medicare and Medicaid Services (CMS). Prothrombin time (INR) monitor for home anticoagulation management (#CAG-00087N). National Coverage Analysis (NCA). Baltimore, MD: CMS; September 18, 2001. Available at: http://cms.hhs.gov/ncdr/memo.asp?id=72.

Accessed May 13, 2003. Horstkotte D, Piper C. Improvement of oral anticoagulation therapy by INR self-management. J Heart Valve Dis. 2004;13 (3):335-338. Tripodi A. Prothrombin time international normalized ratio monitoring by self-testing. Curr Opin Hematol. 2004;11 (3):141-145. Jackson SL, Peterson GM, Vial JH, Jupe DM. Improving the outcomes of anticoagulation: An evaluation of home follow-up of warfarin initiation.

J Intern Med. 2004;256 (2):137-144. Yang DT, Robetorye RS, Rodgers GM. Home prothrombin time monitoring: A literature analysis. Am J Hematol. 2004;77 (2):177-186. Gardiner C, Williams K, Mackie IJ, et al. Patient self-testing is a reliable and acceptable alternative to laboratory INR monitoring. Br J Haematol. 2005;128 (2):242-247. Fitzmaurice DA. Oral anticoagulation control: The European perspective. J Thromb Thrombolysis. 2006;21 (1):95-100. American Medical Association (AMA). Home anticoagulation monitoring.

Report of the Council on Science and Public Health. Chicago, IL: AMA; 2007. Brown A, Wells P, Jaffey J, et al. Point-of-care monitoring devices for long-term oral anticoagulation therapy: Clinical and cost effectiveness. Technology Report No. 72. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health (CADTH); February 2007. Available at: http://www.cadth.ca/index.php/en/hta/reports-publications/search/publication/679. Accessed February 20, 2007.

Center for Medicare & Medicaid Services (CMS). Decision memo for prothrombin time (INR) monitor for home anticoagulation management (CAG-00087R). Baltimore, MD: CMS; March 19, 2008. Available at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=209. Accessed April 29, 2008. Centers for Medicare & Medicaid Services (CMS). National coverage determination (NCD) for home prothrombin time/international normalized ratio (PT/INR) monitoring for anticoagulation management (190.11). Baltimore, MD: CMS; March 19, 2008. Bradbury MJ, Taylor G, Short P, Williams MD. A comparative study of anticoagulant control in patients on long-term warfarin using home and hospital monitoring of the international normalised ratio.

Arch Dis Child. 2008;93 (4):303-306. Ontario Ministry of Health and Long-term Care, Medical Advisory Secretariat (MAS). Point-of-care international normalized ratio (INR) monitoring devices for patients on long-term oral anticoagulation therapy: An evidence-based analysis. Ontario Health Technology Assessment Series. 2009; 9 (12):1-114. Ryan F, Byrne S, O'Shea S. Randomized controlled trial of supervised patient self-testing of warfarin therapy using an internet-based expert system. J Thromb Haemost. 2009;7 (8):1284-1290. Plesch W, van den Besselaar AM. Validation of the international normalized ratio (INR) in a new point-of-care system designed for home monitoring of oral anticoagulation therapy.

Int J Lab Hematol. 2009;31 (1):20-25. Greenway A, Ignjatovic V, Summerhayes R, et al. Point-of-care monitoring of oral anticoagulation therapy in children. Comparison of the Coagu Chek XS system with venous INR and venous INR using an International Reference Thromboplastin preparation (r TF/95). Thromb Haemost. 2009;102 (1):159-165. Sobieraj-Teague M, Daniel D, Farrelly B, et al. Accuracy and clinical usefulness of the Coagu Chek S and XS Point of Care devices when starting warfarin in a hospital outreach setting.

Thromb Res. 2009;123 (6):909-913. Ryan F, O'Shea S, Byrne S. The reliability of point-of-care prothrombin time testing. A comparison of Coagu Chek S and XS INR measurements with hospital laboratory monitoring. Int J Lab Hematol. 2010;32 (1 Pt 1):e26-e33. Dolor RJ, Ruybalid RL, Uyeda L, et al; THINRS Site Investigators. An evaluation of patient self-testing competency of prothrombin time for managing anticoagulation: pre-randomization results of VA Cooperative Study #481 -- The Home INR Study (THINRS). J Thromb Thrombolysis. 2010;30 (3):263-275. Matchar DB, Jacobson A, Dolor R, et al; THINRS Executive Committee and Site Investigators. Effect of home testing of international normalized ratio on clinical events. N Engl J Med. 2010;363 (17):1608-1620.

Bonaros N, Mueller MR, Salat A, et al. Extensive coagulation monitoring in patients after implantation of the Micro Med Debakey continuous flow axial pump. ASAIO J. 2004;50 (5):424-431. Joshi A, Magder LS, Kon Z, et al. Association between prothrombin activation fragment (F1.2), cerebral ischemia (S-100beta) and international normalized ratio (INR) in patients with ventricular assisted devices.

Interact Cardiovasc Thorac Surg. 2007;6 (3):323-327. Bloomfield HE, Krause A, Greer N, et al. Meta-analysis: Effect of patient self-testing and self-management of long-term anticoagulation on major clinical outcomes.

Ann Intern Med. 2011;154 (7):472-482. Nutescu EA, Bathija S, Sharp LK, et al. Anticoagulation patient self-monitoring in the United States: Considerations for clinical practice adoption. Pharmacotherapy. 2011;31 (12):1161-1174. Holbrook A, Schulman S, Witt DM, et al. ; American College of Chest Physicians.

Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141 (2 Suppl):e152S-84S. National Institute for Health and Care Excellence (NICE). Atrial fibrillation and heart valve disease: Self-monitoring coagulation status using point-of-care coagulometers (the Coagu Chek XS system and the INRatio2 PT/INR monitor). NICE Diagnostics Guidance 14. London, UK: NICE; September 24, 2014. De Santis G, Hogan-Schlientz J, Liska G, et al. STABLE results: Warfarin home monitoring achieves excellent INR control. Am J Manag Care. 2014;20 (3):202-209. Matchar DB, Love SR, Jacobson AK, et al. The impact of frequency of patient self-testing of prothrombin time on time in target range within VA Cooperative Study #481: The Home INR Study (THINRS), a randomized, controlled trial. J Thromb Thrombolysis. 2015;40 (1):17-25. "

ed. Your costs in Original Medicare If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment: You may need to rent the equipment. You may need to buy the equipment.

Your Medicare Coverage

Is my test, item, or service covered? Go Lancet devices & lancets How often is it covered? Medicare Part B (Medical Insurance) covers some diabetic test supplies, including lancet devices and lancets as supplies used with durable medical equipment (DME). Who's eligible? All people with Medicare Part B who have diabetes are cover

You may be able to choose whether to rent or buy the equipment. Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them.

It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment.

If suppliers don't accept assignment, there’s no limit on the amount they can charge you. Competitive Bidding Program If you live in or visit certain areas, you may be affected by Medicare's Competitive Bidding Program . In most cases, Medicare will only help pay for these equipment and supplies if they're provided by contract suppliers when both of these apply: You have Original Medicare. You get competitively bid equipment and supplies in competitive bidding areas. Contract suppliers can't charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.

Note You may need to use specific suppliers for some types of diabetes testing supplies. Learn more about Medicare's National Mail-Order Program for diabetes testing supplies.

Note To find out how much your test, item, or service will cost, talk to your doctor or health care provider.

The specific amount you’ll owe may depend on several things, like: Other insurance you may have How much your doctor charges Whether your doctor accepts assignment The type of facility Where you get your test, item, or service Related resources Diabetes supplies & services Medicare & You: diabetes (video)Where to get covered DME items More information about DMECompetitive Bidding Program Return to search results

Medicare Part B is for outpatient care, durable medical equipment, and home health care. Part D is for prescription coverage. Not all persons will elect to have coverage in all three areas. Medicaid is more comprehensive in its coverage, but the benefits are specific to the age group.

Medicare vs. Medicaid: Understanding the Differences and Dual Eligibility

"Medicare vs. Medicaid: Understanding the Differences and Dual Eligibility Page Reviewed / Updated - May 2016Find Financial Assistance for Eldercare Get Help Qualifying for Medicaid Find Affordable Care Providers Learn More about Medicare Learn More about Medicaid Table of Contents Differences Between Medicare and Medicaid Compare Benefits Eligibility Requirements Dual Eligibility What are the Differences Between Medicare and Medicaid?

Medicare is a federal health insurance program open to Americans aged 65 and older, and those with specific disabilities who are under the age of 65. Medicaid, a combined state and federal program, is a state-specific insurance program for low-income individuals with limited financial assets, regardless of their age.

Medicare, generally speaking, offers the same benefits to all eligible participants. However, coverage is divided into Medicare Part A, Part B, and Part D. Medicare Part A is for hospice care, skilled nursing facility care, and inpatient hospital care.

Children have different eligibility requirements and receive different benefits from low-income adults and from elderly or disabled persons. Did You Know? Free assistance is available for seniors to help them determine their Medicaid eligibility.

Learn more. Medicare vs. Medicaid Compare Benefits In the context of long term care for the elderly, Medicare’s benefits are very limited. Medicare does not pay for personal care (also known as custodial care or non-medical care). Medicare will pay for a very limited number of days of skilled nursing (also referred to as nursing home care).

Medicare will also pay for some home health care, provided it is medical in nature. Medicaid, being state run, has different benefits in each state. Generally speaking, Medicaid pays for nursing home care and through waiver programs, pays for home care, personal care and assisted living.

To avoid confusion, it is worth noting that Medicaid is referred to by different names in different states. For example, in California it is called Medi-Cal, in Kansas it is called Kan Care, and in Massachusetts it is called Mass Health.

How Does Medicare’s Eligibility Requirements Compare to Medicaid’s? Eligibility in 2016 Medicare Medicaid Age Limit 65 and older No age limit Income Limit No income limit Approximately $2,199 / month *Asset Limit No asset limit Approximately $2,000 **Health Restrictions None Some depending on program / waiver*Some states have ""spend-down"" Medicaid in which income limits are considered relative to care costs.

**Varies dramatically by state and may go away with Obamacare for certain eligibility groups Can One Have Dual Eligibility for both Medicare and Medicaid? Yes, these are not mutually exclusive programs. These persons are referred to as having Dual Eligibility, Dual Eligibles or often simply “Duals”.

Typically, Medicaid will pay for their Medicare premiums and co-payments. In fact, many states have special programs intended to make it easier for seniors to manage their dual eligibility status as it can be confusing to know where to turn for what services. Did You Know? There are also programs called Medicare Saving Programs for low-income seniors that don’t quite qualify for Medicaid. "

da Yes, Medicare provides coverage for diabetic test strips under Part B - they're viewed as a type of durable medical equipment (DME). You must be enrolled in Medicare and be diabetic to have the test strips covered.

Will Medicare Pay For Diabetic Test Strips?

Will Medicare Pay For Diabetic Test Strips? Asked March 23, 2014 in Medicare Insurance15433 POINTSContact Meview profile Jason Goldenzweig PROCo-Founder, Term Insurance Brokers.com, Goldenzweig Financial Group, Las Vegas, Neva

In general, Medicare will cover approximately 80% of the cost - you will be responsible for the other 20%.

Answered on March 23, 2014+1 +1 this answer flag this answerview more answers by Jason Goldenzweig315 POINTSContact Meview profile Belinda www.myseniorventure.com/answers Senior Benefits Insurance Services, CA, AZ, UTMedicare covers testing strips - under Part B. Medicare Part A & B only covers 80% of anything, but if you have a Medicare Advantage plan or a Medicare Supplement - this helps cover all or most of the 20% you might be left with. Some Medicare Advantage plans cover the strips at 100%, some would leave you with a small copay, instead of the full 20%.

Check with your Advantage or Supplement plan to find out exactly what you will pay for your strips.

Belinda myseniorventure.com/answers Answered on March 25, 2014+1 +1 this answer flag this answerview more answers by Belinda www.myseniorventure.com/answers2310 POINTSContact Meview profile Steve Adlman PROOwner, Alabama Medicare Plans, Birmingham, Alabama Diabetes Supplies & Services Supplies: Medicare Part B (Medical Insurance) covers some diabetes supplies, including: • Blood sugar (glucose) test strips • Blood sugar testing monitors • Insulin • Lancet devices and lancets • Glucose control solutions • Therapeutic shoes or inserts Part B covers some diabetes services, including: • Diabetes self-management training • Yearly eye exam • Foot exam • Glaucoma tests • Nutrition therapy services (medical)Answered on January 22, 2016+0 +1 this answer flag this answerview more answers by Steve Adlman Did you find these answers helpful? Yes No Add Your Answer To This Question You must be logged in to add your answer.<< Previous Question Questions Home Next Question >>

If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways.

Your Medicare Coverage

Is my test, item, or service covered? Go Blood sugar (glucose) test strips How often is it covered?

Medicare Part B (Medical Insurance) covers some diabetic test supplies, including blood sugar test strips as durable medical equipment (DME). Who's eligible? All people with Part B who have diabetes are covered. Your costs in Original Medicare

Depending on the type of equipment: You may need to rent the equipment. You may need to buy the equipment.

You may be able to choose whether to rent or buy the equipment. Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them.

It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment.

If suppliers don't accept assignment, there’s no limit on the amount they can charge you. Competitive Bidding Program If you live in or visit certain areas, you may be affected by Medicare's Competitive Bidding Program . In most cases, Medicare will only help pay for these equipment and supplies if they're provided by contract suppliers when both of these apply: You have Original Medicare. You get competitively bid equipment and supplies in competitive bidding areas. Contract suppliers can't charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.

Note You may need to use specific suppliers for some types of diabetes testing supplies. Learn more about Medicare's National Mail-Order Program for diabetes testing supplies.

Note To find out how much your test, item, or service will cost, talk to your doctor or health care provider.

The specific amount you’ll owe may depend on several things, like: Other insurance you may have How much your doctor charges Whether your doctor accepts assignment The type of facility Where you get your test, item, or service Related resources Diabetes supplies & services Medicare & You: diabetes (video)Where to get covered DME items More information about DMECompetitive Bidding Program Return to search results

y Aetna considers transcutaneous electrical nerve stimulators (TENS) medically necessary durable medical equipment (DME) when used as an adjunct or as an alternative to the use of drugs either in the treatment of acute post-operative pain in the first 30 days after surgery, or for certain types of chronic, intractable pain not adequately responsive to oth

Electrical Stimulation for Pain

"Electrical Stimulation for Pain Print Share Number: 0011 (Replaces CPBs 12, 335)Polic

er methods of treatment including, as appropriate, physical therapy and pharmacotherapy. Aetna considers TENS experimental and investigational for acute pain (less than 3 months duration) other than post-operative pain. TENS is also considered experimental and investigational for any of the following (not an all-inclusive list) because there is inadequate scientific evidence to support its efficacy for these specific types of pain: Acute and chronic headaches,adhesive capsulitis (frozen shoulder),chemotherapy-induced peripheral neuropathy,chronic low back pain,deep abdominal pain,fibromyalgia,hip fracture pain,musculoskeletal pain in hemophilia,neuropathic pain,pain management in burn persons,pelvic pain,peripheral arterial disease,phantom pain,post-total knee arthroplasty pain,rotator cuff disease (e.g., calcific tendinitis, rotator cuff tendinitis, and subacromial impingement syndrome),stump pain,temporomandibular joint (TMJ) pain Note: When TENS is used for acute post-operative or chronic intractable pain, Aetna considers use of the device medically necessary initially for a trial period of at least 1 month but not to exceed 2 months.

The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain. After this 1-month trial period, continued TENS treatment may be considered medically necessary if the treatment significantly alleviates pain and if the attending physician documents that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.

The physician's records must document a reevaluation of the member at the end of the trial period, must indicate how often the member used the TENS unit, the typical duration of use each time, and the results.

The physician ordering the TENS unit must be the attending physician or a consulting physician for the disease or condition resulting in the need for the TENS unit. If the TENS unit produces incomplete relief, further evaluation with percutaneous electrical nerve stimulation (PENS) may be indicated.

This clinical policy is consistent with Medicare DME MAC guidelines. Aetna considers a form-fitting conductive garment medically necessary DME only when it has been approved for marketing by the FDA, has been prescribed by a doctor for delivering TENS for one of the medically necessary indications listed above, and any of the following criteria is met: The member can not manage without the conductive garment due to the large area or the large number of sites to be stimulated, and the stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires; or The member has a medical need for rehabilitation strengthening following an injury where the nerve supply to the muscle is intact; or The member has a skin problem or other medical conditions that precludes the application of conventional electrodes, adhesive tapes, and lead wires; or The member requires electrical stimulation beneath a cast to treat disuse atrophy, where the nerve supply to the muscle is intact.

Aetna considers stellate ganglion blockade using TENS experimental and investigational because its clinical value has not been established. Aetna considers interferential stimulation (e.g., RS-4i Sequential Stimulator) experimental and investigational for the reduction of pain and edema and all other indications because its effectiveness has not been established.

Aetna considers percutaneous electrical nerve stimulation (PENS) medically necessary DME forup to a 30-day period for the treatment of members with chronic low back pain secondary to degenerative disc disease when PENS is used as part of a multi-modality rehabilitation program that includes exercise, andthe treatment of members with diabetic neuropathy or neuropathic pain who failed to adequately respond to conventional treatments including three or more of the following groups of agents: anti-convulsants (e.g., pregabalin), anti-depressants (e.g., amitriptyline, and duloxetine), opioids (e.g., morphine sulphate and tramadol), and other pharmacological agents (e.g., capsaicin and isosorbide dinitrate spray).

Aetna considers PENS experimental and investigational for the treatment of chronic neck pain, and all other indications because its effectiveness for these indications has not been established.

Aetna considers peripherally implanted nerve stimulators (e.g., Stim Router System) medically necessary DME for treatment of members with intractable neurogenic pain when all of the following criteria are met: Member has chronic intractable pain, refractory to other methods of treatment (e.g., analgesics, physical therapy, local injection, surgery), and Member is not addicted to drugs (per American Society of Addiction Medicine guidelines), and There is no psychological contraindication to peripheral nerve stimulation, and;There is objective evidence of pathology (e.g., electromyography), and;Trial of transcutaneous stimulation was successful (resulting in at least a 50 % reduction in pain).

Note: Peripheral nerve stimulation is considered experimental and investigational for post-herpetic neuralgia and all other indications because its effectiveness for these indications has not been established. Aetna considers H-WAVE ® type stimulators experimental and investigational for diabetic peripheral neuropathy and for all other indications including any of the following indications because their effectiveness for these indications has not been established.

To accelerate healing; or To reduce edema; or To reduce pain from causes other than chronic diabetic peripheral neuropathy; or To treat chronic pain due to ischemia. Aetna considers intramuscular stimulation experimental and investigational for the management of members with soft-tissue or neuropathic pain and all other indications because its effectiveness has not been established. Aetna considers sympathetic therapy (Dynatronics Corporation, Salt Lake City, UT) experimental and investigational since its effectiveness has not been established.

Aetna considers electroceutical therapy (also known as bioelectric nerve block) experimental and investigational for the treatment of acute pain or chronic pain (e.g., back pain, diabetic pain, joint pain, fibromyalgia, headache, and reflex sympathetic dystrophy) or other indications because there is a lack of scientific evidence regarding the effectiveness of this technology.

Note: Other terms used to refer to electroceutical therapy devices include ""non-invasive neuron blockade"" devices, ""electroceutical neuron blockade"" devices, and ""bioelectric treatment systems. ""Aetna considers the Electro-Acuscope Myopulse Therapy System experimental and investigational for the treatment of pain and tissue damage and all other indications because its effectiveness has not been demonstrated in the peer-reviewed scientific literature.

Aetna considers electrical stimulation of the sacral nerve roots or lumbosacral plexus experimental and investigational for the treatment of chronic pelvic or abdominal pain or other indications because the effectiveness of these interventions has not been established. Aetna considers microcurrent electrical nerve stimulation (MENS) therapy (including, but not limited to, Algonix, Alpha-Stim 100, Electro-Myopulse 75L, electro-Lyoscope 85P, KFH Energy, MENS 2000-D, MICROCURRENT or Myopulse 75C) experimental and investigational for the treatment of chronic back pain and all other indications because its effectiveness has not been established.

Aetna considers Scrambler therapy/the Calmare therapy device (also known as transcutaneous electrical modulation pain reprocessing (TEMPR)) experimental and investigational for the treatment of cancer pain, chronic pain, post-mastectomy pain, and other indications because of insufficient evidence regarding its effectiveness.

Aetna considers non-invasive interactive neurostimulation (e.g., the Inter X 1000 neurostimulator device experimental and investigational for the treatment of chronic pain and other indications (e.g., ankle fracture, knee osteoarthritis and neck pain) because of insufficient evidence regarding its effectiveness.

Aetna considers peripherally implanted nerve stimulation (also known as peripheral subcutaneous field stimulation (PSFS) or peripheral nerve field stimulation (PNFS)) experimental and investigational for the treatment of chronic pain and other indications (e.g., angina, notalgia paraesthetica) because of insufficient evidence regarding its effectiveness.

Aetna considers electro-therapeutic point stimulation (also known as microcurrent point stimulation) experimental and investigational for the treatment of chronic pain and other indications because of insufficient evidence regarding its effectiveness.

Aetna considers pulse stimulation (e.g., the P-STIM device) experimental and investigational for the treatment of cervicalgia, cervical radiculopathy, cervical spasm, chronic neck pain, failed back syndrome, lumbago, lumbar muscle spasm, lumbosacral myofasciitis, lumbosacral radiculopathy, osteoarthritis of the knee, post-herpetic neuralgia, or other conditions because its clinical value has not been established.

Aetna considers TENS with low level laser therapy (LLLT) (e.g., the Neurolumen device) for the treatment of Morton’s neuroma and all other indications experimental and investigational because its clinical value has not been established.

Aetna considers non-invasive/no-incision pain procedure (NIP) device experimental and investigational for the treatment of chronic pain (arthritis, cancer pain, cervical pain, fibromyalgia, joint pain, low back pain, migraines, post-operative pain, and sciatica; not an all-inclusive list) and all other conditions (e.g., anxiety, depression and insomnia; not an all-inclusive list) because its clinical value has not been established.

Aetna considers Electro-Analgesia Treatment (EAT) using the Synaptic electrical stimulator with or without peripheral nerve blocks experimental and investigational for peripheral neuropathy and all other indications. Aetna considers electrotherapy for the treatment of adhesive capsulitis (frozen shoulder) experimental and investigational because its effectiveness of for this indication has not been established. Aetna considers Cefaly transcutaneous electrical stimulator headband experimental and investigational for migraine headache prevention and treatment and all other indications.

Aetna considers percutaneous neuromodulation therapy (e.g., Vertis PNT, Biowave PRO) experimental and investigational for pain and other indications. Aetna considers the Quell device experimental and investigational for all indications. Aetna considers SENSUS transcutaneous electrical nerve stimulation experimental and investigational for diabetic neuropathy and other indications. Aetna considers transcutaneous electrical joint stimulation devices/pulsed electrical stimulation (PES) (e.g., the Bioni Care device, Jstim 1000) experimental and investigational for the treatment of knee osteoarthritis. Aetna considers pulsed electrical stimulator (PES) experimental and investigational for soft-tissue injuries (e.g., ankle sprain) and all other indications because its effectiveness has not been established.

Aetna considers variable muscle stimulators experimental and investigational because their effectiveness has not been established. Aetna considers combined therapy high frequency electrical stimulation and peripheral nerve block (also referred to as combination electrochemical therapy, combination electrochemical treatment, or CET) experimental and investigational for all indications.

(See CPB 0729 - Diabetic Neuropathy: Selected Treatments )Aetna considers galvanic stimulation or other types of electrical stimulation for the treatment of peripheral arterial disease experimental and investigational because their effectiveness for this indication has not been established.

Aetna considers combination stimulation devices experimental and investigational for all indications: ICS and muscle stimulator (e.g., RS-4i sequential stimulator, EMSI TENS/EMS-14); or TENS with ICS; or TENS with NMES (e.g., Empi Phoenix, QB1 System); or TENS with ultrasound device.

Note: Below is a list of CPBs that address other types of electrical stimulation: CPB 0175 - High-Frequency Pulsed Electromagnetic Stimulation CPB 0191 - Vagus Nerve Stimulation CPB 0194 - Spinal Cord Stimulation CPB 0208 - Deep Brain Stimulation CPB 0223 - Urinary Incontinence CPB 0302 - Xerostomia: Selected Treatments CPB 0327 - Infertility (discusses electroejaculation)CPB 0343 - Bone Growth Stimulators CPB 0398 - Idiopathic Scoliosis (discusses surface electrical muscle stimulation)CPB 0406 - Tinnitus Treatments (discusses the use of TENS)CPB 0469 - Transcranial Magnetic Stimulation and Cranial Electrical Stimulation CPB 0545 - Electrothermal Arthroscopy CPB 0676 - Electrical Stimulation for Nausea, Vomiting, and Motion Sickness (Prima Bella and Relief Band) and Other Selected Indications CPB 0677 - Functional Electrical Stimulation and Neuromuscular Electrical Stimulation (for Bell’s palsy, cerebral palsy, diaphragmatic pacing, neurogenic bladder, spinal cord injury, and stroke)CPB 0678 - Gastric Pacing and Gastric Electrical Stimulation CPB 0679 - Levator Syndrome Treatments CPB 0680 - Electrical Stimulation for Chronic Ulcers CPB 0707 - Headaches: Invasive Procedures (discusses electrical stimulation of the occipital nerve for occipital neuralgia)CPB 0729 - Diabetic Neuropathy: Selected Treatments (discusses percutaneous electrical stimulation for the treatment of diabetic neuropathy)Background The following are brief descriptions of various types of electrical stimulation discussed in this CPB, and a summary of available evidence: Transcutaneous Electrical Nerve Stimulator (TENS): A TENS is a device which utilizes electrical current delivered through electrodes placed on the surface of the skin to decrease the patient's perception of pain by inhibiting the transmission of afferent pain nerve impulses and/or stimulating the release of endorphins.

A TENS unit must be distinguished from other electrical stimulators (e.g., neuromuscular stimulators) which are used to directly stimulate muscles and/or motor nerves. Transcutaneous electrical nerve stimulation is characterized by biphasic current and selectable parameters such as pulse rate and pulse width. In theory, TENS stimulates sensory nerves to block pain signals; it also stimulates endorphin production to help normalize sympathetic function.

Most TENS units produce current of 1 to 80 microampere (m A), 9 V (average), 2 to 1000 Hz, with a pulse width of 250 to 400 microseconds (m S). Transcutaneous electrical nerve stimulation has been widely used in the treatment of various types of pain.

It has been shown that TENS is highly effective in alleviating pain and reducing analgesic medications following cesarean section, orthopedic and thoracic operations as well as mixed surgical procedures (AHCPR, 1992). Moreover, TENS has been found to be beneficial also to those who suffer from acute musculoskeletal pain (Long, 1991).

On the other hand, the use of TENS in the treatment of chronic malignant pain is sparse and its effectiveness remains unproven. Studies by Ventafridda and colleagues (1979) reported that of the 159 cancer patients who experienced short-term pain relief with TENS therapy, 58 % of them found the treatment ineffective by day 10, and only 35 % of these subjects continued its use after 1 month. In another group of 37 patients, pain was markedly reduced in 96 % of them during the first 10 days of TENS treatment.

However, pain reduction was found only in 33 % of the subjects during the second 10 days, and to only 11 % during the third 10 days.

Physical mobility was improved initially in 76 % of patients, but dropped to 19 % by the end of 1 month (Ventafridda et al, 1979). The Canadian Coordinating Office for Health Technology Assessment evaluated the clinical value of TENS in pain management and concluded that there is little evidence of the effectiveness of TENS in treating chronic pain (1995).

On June 8, 2012, the Centers for Medicare & Medicaid Services (CMS) rendered a decision memo for TENS for chronic low back pain. It states that TENS is not reasonable and necessary for the treatment of chronic low back pain. The CMS will only cover TENS if individuals are enrolled in an approved clinical study meeting specific requirements. The Centers for Medicare & Medicaid Services (2012) has issued a decision memorandum concluding that TENS not reasonable and necessary for the treatment of chronic low back pain.

For purposes of the decision memorandum, chronic low back pain was defined as an episode of low back pain that has persisted for three months or longer; and is not a manifestation of a clearly defined and generally recognizable primary disease entity. For example, there are cancers that, through metastatic spread to the spine or pelvis, may elicit pain in the lower back as a symptom; and certain systemic diseases such as rheumatoid arthritis and multiple sclerosis manifest many debilitating symptoms of which low back pain is not the primary focus.

The CMS decision memorandum stated that the evidence demonstrates that the use of TENS for chronic low back pain as defined within the scope of this analysis does not produce a clinically meaningful improvement in any of the considered health outcomes The decision memorandum stated that it is apparent that sham (placebo) TENS produces equivalent analgesia as active TENS.

In an evidence-based review, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology evaluated the effectiveness of TENS in the treatment of pain in neurological disorders (Dubinsky and Miyasaki, 2010).

There are conflicting reports of TENS compared to sham TENS in the treatment of chronic low back pain (LBP), with 2 Class II studies showing benefit, while 2 Class I studies and another Class II study not showing benefit. Because the Class I studies are stronger evidence, TENS is established as ineffective for the treatment of chronic LBP.

On the other hand, TENS is probably effective in treating painful diabetic neuropathy (2 Class II studies. The authors concluded that: TENS is not recommended for the treatment of chronic LBP (Level A), and TENS should be considered in the treatment of painful diabetic neuropathy (Level B).

They stated that further research into the mechanism of action of TENS is needed, as well as more rigorous studies for determination of efficacy. Guidelines on treatment of LBP from the National Collaborating Centre for Primary Care (Savigny et al, 2009) found insufficient evidence for the use of TENS in LBP and recommended against its use for that indication.

In a Cochrane review, Mulvey et al (2010) evaluated the analgesic effectiveness of TENS for the treatment of phantom pain and stump pain following amputation in adults. These investigators searched MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Psyc INFO, AMED, CINAHL, PEDRO and SPORTDiscus (February 2010).

Only randomized controlled trials (RCTs) investigating the use of TENS for the management of phantom pain and stump pain following an amputation in adults were included. Two review authors independently assessed trial quality and extracted data. It was planned that where available and appropriate, data from outcome measures were to be pooled and presented as an overall estimate of the effectiveness of TENS.

No RCTs that examined the effectiveness of TENS for the treatment of phantom pain and stump pain in adults were identified by the searches.

The authors concluded that there were no RCTs on which to judge the effectiveness of TENS for the management of phantom pain and stump pain. The published literature on TENS for phantom pain and stump pain lacks the methodological rigor and robust reporting needed to confidently assess its effectiveness.

They stated that further RCT evidence is needed before such a judgment can be made. Johnson et al (2015) updated of a Cochrane review published in 2010 on TENS for phantom pain and stump pain following amputation in adults. The authors concluded that there were no RCTs to judge the effectiveness of TENS for the management of phantom pain and stump pain.

The published literature on TENS for phantom pain and stump pain lacks the methodological rigor and robust reporting needed to confidently assess its effectiveness. They stated that further RCT evidence is needed before an assessment can be made. Since publication of the original version of this review, these investigators have found no new studies and their conclusions remain unchanged.

Zeng et al (2015) examined the effectiveness of different electrical stimulation (ES) therapies in pain relief of patients with knee osteoarthritis (OA). Electronic databases including MEDLINE, Embase and Cochrane Library were searched through for RCTs comparing any ES therapies with control interventions (sham or blank) or with each other.

Bayesian network meta-analysis was used to combine both the direct and indirect evidence on treatment effectiveness. A total of 27 trials and 6 types of ES therapies, including high-frequency TENS (h-TENS), low-frequency TENS (l-TENS), neuromuscular electrical stimulation (NMES), interferential current (IFC), pulsed electrical stimulation (PES), and noninvasive interactive neurostimulation (NIN), were included. Interferential current is the only significantly effective treatment in terms of both pain intensity and change pain score at last follow-up time-point when compared with the control group.

Meanwhile, IFC showed the greatest probability of being the best option among the 6 treatment methods in pain relief.

These estimates barely changed in sensitivity analysis. However, the evidence of heterogeneity and the limitation in sample size of some studies could be a potential threat to the validity of results. The authors conclude that IFC seems to be the most promising pain relief treatment for the management of knee OA.

However, evidence was limited due to the heterogeneity and small number of included trials. Although the recommendation level of the other ES therapies is either uncertain (h-TENS) or not appropriate (l-TENS, NMES, PES and NIN) for pain relief, it is likely that none of the interventions is dangerous. Cheing and Luk (2005) examined the clinical effectiveness of high-frequency (HF) TENS for reducing hyper-sensitivity of the hand in patients with neuropathic pain.

A total of 19 patients suffering from hand hyper-sensitivity were randomly assigned into either a treatment or a placebo group. A visual analog scale (VAS) and the Downey Hand Center Hand Sensitivity Test were used to measure the tactile tolerance of the hand. Grip strength was assessed by a grip dynamometer. Daily applications of electrical stimulation were provided for 2 weeks.

Significantly lower pain scores were found in the treatment group than in the placebo group by day 7 and day 11. The ranking of 10 dowel textures of the Downey Hand Center Hand Sensitivity Test in the treatment group was significantly higher than in the placebo group by day 7 and day 11.

However, no significant inter-group difference was found in grip strength. The Ad hoc Committee of the Croatian Society for Neurovascular Disorders and the Croatian Medical Association's recommendations for neuropathic pain treatment (Demarin et al, 2008) stated that damage to the somatosensory nervous system poses a risk for the development of neuropathic pain. Such an injury to the nervous system results in a series of neurobiological events resulting in sensitization of both the peripheral and central nervous system. The diagnosis of neuropathic pain is based primarily on the history and physical examination finding.

Although monotherapy is the ideal approach, rational poly-pharmacy is often pragmatically used. Several classes of drugs are moderately effective, but complete or near-complete relief is unlikely. Anti-depressants and anti-convulsants are most commonly used. Opioid analgesics can provide some relief but are less effective than for nociceptive pain; adverse effects may prevent adequate analgesia. Topical drugs and a lidocaine-containing patch may be effective for peripheral syndromes. Sympathetic blockade is usually ineffective except for some patients with complex regional pain syndrome. TENS was not mentioned as a therapeutic option. Norrbrink (2009) assessed the short-term effects of HF and low-frequency (LF) TENS for neuropathic pain following spinal cord injury (SCI).

A total of 24 patients participated in the study. According to the protocol, 50 % of the patients were assigned to HF (80 Hz) and 50 % to LF (burst of 2 Hz) TENS. Patients were instructed to treat themselves 3 times daily for 2 weeks. After a 2-week wash-out period, patients switched stimulation frequencies and repeated the procedure.

Results were calculated on an intent-to-treat basis. No differences between the 2 modes of stimulation were found. On a group level, no effects on pain intensity ratings or ratings of mood, coping with pain, life satisfaction, sleep quality, or psychosocial consequences of pain were seen.

However, 29 % of the patients reported a favorable effect from HF and 38 % from LF stimulation on a 5-point global pain-relief scale. Six of the patients (25 %) were, at their request, prescribed TENS stimulators for further treatment at the end of the study.

The authors concluded that TENS merits consideration as a complementary treatment in patients with SCI and neuropathic pain. The mild benefits observed -- 29 % of subjects in the HF group and 38 % of subjects in the LF group could be a placebo effect.

Moharic and Burger (2010) examined if TENS improves small fiber function diminished because of painful diabetic neuropathy. A total of 46 patients with painful diabetic neuropathy were treated with TENS 3 consecutive hours a day for 3 weeks.

Treatment effect was evaluated with cold, warm, cold pain and heat pain thresholds, vibration perception thresholds and touch perception thresholds. In all patients, thermal-specific and thermal pain sensitivity determination showed quantitative and qualitative abnormalities in all the measured spots. After the TENS therapy, no statistically significant changes in cold, warm, cold pain, heat pain, vibratory perception and touch perception thresholds were observed in the stimulated area. TENS did not alter C, Aδ nor Aβ fiber-mediated perception thresholds. The authors noted that the observed changes at thenar were probably because of central mechanisms.

In general, analgesic mechanisms of TENS are likely to be complex. Jin et al (2010) evaluated the effectiveness of TENS on diabetic peripheral neuropathy (DPN). Randomized controlled trials (RCTs) comparing TENS with routine care, pharmacological interventions or placebo devices on patients with symptomatic DPN, were identified by electronic and manual searches.

Studies were selected and available data were extracted independently by 2 investigators. Meta-analysis was performed by Rev Man 4.2.8 software.

A total of 3 RCTs involving 78 patients were included in this study. The reductions in mean pain score were significantly greater in TENS group than in placebo TENS group in 4 weeks and 6 weeks follow-up [4 weeks, standard mean difference (SMD) -5.37, 95 % confidence interval [CI]: -6.97 to -3.77; 6 weeks, SMD-1.01, 95 % CI: -2.01 to -0.01)], but not in 12 weeks follow-up [SMD-1.65, 95 % CI: -4.02 to 0.73].

TENS therapy was associated with significantly subjective improvement in overall neuropathic symptoms in 12 weeks follow-up [WMD-0.18, 95 % CI: -0.32 to -0.051].

No TENS-related adverse events were registered in TENS group. The authors concluded that TENS therapy may be an effective and safe strategy in treatment of symptomatic DPN. They stated that due to small sample and short-term treatment duration, large multi-center RCTs are needed to further evaluate the long-term effect of TENS on DPN. Johnson and Bjordal (2011) stated that the management of neuropathic pain is challenging, with medication being the first-line treatment.

Transcutaneous electrical nerve stimulation is a non-invasive, self-administered technique that is used as an adjunct to medication. Clinical experience suggested that TENS is beneficial providing it is administered at a sufficiently strong intensity, close to the site of pain.

At present, there are too few RCTs on TENS for neuropathic pain to judge effectiveness. The findings of systematic reviews of TENS for other pain syndromes are inconclusive because trials have a low fidelity associated with inadequate TENS technique and infrequent treatments of insufficient duration. The use of electrode arrays to spatially target stimulation more precisely may improve the efficacy of TENS in the future.

In a systematic review, Abou-Setta (2011) reviewed the benefits and harms of pharmacological and non-pharmacological interventions for managing pain after hip fracture. A total of 25 electronic databases (January 1990 to December 2010), gray literature, trial registries, and reference lists, with no language restrictions were searched.

Multiple reviewers independently and in duplicate screened 9,357 citations to identify RCT); non-RCTs; and cohort studies of pain management techniques in older adults after acute hip fracture. Independent, duplicate data extraction and quality assessment were conducted, with discrepancies resolved by consensus or a third reviewer. Data extracted included study characteristics, inclusion and exclusion criteria, participant characteristics, interventions, and outcomes. A total of 83 unique studies (64 RCTs, 5 non-RCTs, and 14 cohort studies) were included that addressed nerve blockade (n = 32), spinal anesthesia (n = 30), systemic analgesia (n = 3), traction (n = 11), multi-modal pain management (n = 2), neurostimulation (n = 2), rehabilitation (n = 1), and complementary and alternative medicine (n = 2). Overall, moderate evidence suggested that nerve blockades are effective for relieving acute pain and reducing delirium.

Low-level evidence suggested that pre-operative traction does not reduce acute pain. Evidence was insufficient on the benefits and harms of most interventions, including spinal anesthesia, systemic analgesia, multi-modal pain management, acupressure, relaxation therapy, TENS, and physical therapy regimens, in managing acute pain. The authors concluded that nerve blockade seems to be effective in reducing acute pain after hip fracture.

Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions (including TENS) for patients with hip fracture. In a Cochrane review, Page et al (2014) examined the available evidence regarding the benefits and harms of electrotherapy modalities, delivered alone or in combination with other interventions, for the treatment of adhesive capsulitis (frozen shoulder).

These investigators searched CENTRAL, MEDLINE, EMBASE, CINAHL Plus and the Clinical Trials.gov and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) clinical trials registries up to May 2014, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials to identify any other potentially relevant trials.

They included RCTs and controlled clinical trials using a quasi-randomized method of allocation that included adults with adhesive capsulitis and compared any electrotherapy modality to placebo, no treatment, a different electrotherapy modality, or any other intervention. The 2 main questions of the review focused on whether electrotherapy modalities are effective compared to placebo or no treatment, or if they are an effective adjunct to manual therapy or exercise (or both).

The main outcomes of interest were participant-reported pain relief of 30 % or greater, overall pain, function, global assessment of treatment success, active shoulder abduction, quality of life, and the number of participants experiencing any adverse event. Two review authors independently selected trials for inclusion, extracted the data, performed a risk of bias assessment, and assessed the quality of the body of evidence for the main outcomes using the GRADE approach.

A total of 19 trials (1,249 participants) were included in the review; 4 trials reported using an adequate method of allocation concealment and 6 trials blinded participants and personnel.

Only 2 electrotherapy modalities (low-level laser therapy (LLLT) and pulsed electromagnetic field therapy (PEMF)) have been compared to placebo. No trial has compared an electrotherapy modality plus manual therapy and exercise to manual therapy and exercise alone.

The 2 main questions of the review were investigated in 9 trials. Low-quality evidence from 1 trial (40 participants) indicated that LLLT for 6 days may result in improvement at 6 days; 81 % (16/20) of participants reported treatment success with LLLT compared with 10 % (2/20) of participants receiving placebo (risk ratio (RR) 8.00, 95 % CI: 2.11 to 30.34; absolute risk difference 70 %, 95 % CI: 48 % to 92 %).

No participants in either group reported adverse events. These researchers were uncertain whether PEMF for 2 weeks improved pain or function more than placebo at 2 weeks because of the very low quality evidence from 1 trial (32 participants); 75 % (15/20) of participants reported pain relief of 30 % or more with PEMF compared with 0 % (0/12) of participants receiving placebo (RR 19.19, 95 % CI: 1.25 to 294.21; absolute risk difference 75 %, 95 % CI: 53 % to 97 %).

Fifty-five per cent (11/20) of participants reported total recovery of joint function with PEMF compared with 0 % (0/12) of participants receiving placebo (RR 14.24, 95 % CI: 0.91 to 221.75; absolute risk difference 55 %, 95 % CI: 31 to 79). Moderate quality evidence from 1 trial (63 participants) indicated that LLLT plus exercise for 8 weeks probably resulted in greater improvement when measured at the 4th week of treatment, but a similar number of adverse events, compared with placebo plus exercise.

The mean pain score at 4 weeks was 51 points with placebo plus exercise, while with LLLT plus exercise the mean pain score was 32 points on a 100-point scale (mean difference (MD) 19 points, 95 % CI: 15 to 23; absolute risk difference 19 %, 95 % CI: 15 % to 23 %). The mean function impairment score was 48 points with placebo plus exercise, while with LLLT plus exercise the mean function impairment score was 36 points on a 100-point scale (MD 12 points, 95 % CI: 6 to 18; absolute risk difference 12 %, 95 % CI: 6 to 18).

Mean active abduction was 70 degrees with placebo plus exercise, while with LLLT plus exercise mean active abduction was 79 degrees (MD 9 degrees, 95 % CI: 2 to 16; absolute risk difference 5 %, 95 % CI: 1 % to 9 %).

No participants in either group reported adverse events; LLLT's benefits on function were maintained at 4 months. Based on very low quality evidence from 6 trials, these investigators were uncertain whether therapeutic ultrasound, PEMF, continuous short-wave diathermy, Iodex phonophoresis, a combination of Iodex iontophoresis with continuous short-wave diathermy, or a combination of therapeutic ultrasound with TENS were effective adjuncts to exercise.

Based on low or very low quality evidence from 12 trials, these researchers were uncertain whether a diverse range of electrotherapy modalities (delivered alone or in combination with manual therapy, exercise, or other active interventions) were more or less effective than other active interventions (e.g., glucocorticoid injection). The authors concluded that based upon low quality evidence from 1 trial, LLLT for 6 days may be more effective than placebo in terms of global treatment success at 6 days. Based upon moderate quality evidence from 1 trial, LLLT plus exercise for 8 weeks may be more effective than exercise alone in terms of pain up to 4 weeks, and function up to 4 months.

It is unclear whether PEMF is more or less effective than placebo, or whether other electrotherapy modalities are an effective adjunct to exercise.

They stated that further high quality RCTs are needed to establish the benefits and harms of physical therapy interventions (that comprise electrotherapy modalities, manual therapy and exercise, and are reflective of clinical practice) compared to interventions with evidence of benefit (e.g., glucocorticoid injection or arthrographic joint distension). TENS for Pain Management in Burn Persons: In a pilot study, Perez-Ruvalcaba and colleagues (2015) examined the effect of continuous and intermittent TENS on the perception of pain in patients with burns of different types.

This study was conducted in 14 patients (aged 30.9 ± 7.5 years) with 2nd- and 3rd-degree burns of different types.

The burn types included electrical, fire/flame, and chemical. All patients received continuous and intermittent TENS sessions 3 times per week for 4 weeks; each session had a duration of 30 minutes. A pair of electrodes were placed around the burn. The primary effectiveness end-point was the perception of pain assessed by a VAS at baseline and at the 30th day. A significant reduction of pain perception was reported (8.0 ± 1.7 versus 1.0 ± 0.5; p = 0.027) by all patients after TENS therapy.

There were no reports of adverse events during the intervention period. The authors concluded that TENS could be a potential non-pharmacological therapeutic option for pain management in burn patients. These preliminary findings need to be validated by well-designed studies. TENS for Peripheral Arterial Disease: Seenan and colleagues (2016) examined the effects of 2 types of TENS on walking distance and measures of pain in patients with peripheral arterial disease (PAD) and intermittent claudication (IC).

In a phase IIa clinical trial, a total of 40 participants with PAD and IC completed a graded treadmill test on 2 separate testing occasions. Active TENS was applied to the lower limb on the 1st occasion; and placebo TENS, on the 2nd occasion. Participants were divided into 2 experimental groups:one group received high-frequency TENS; and (the 2nd group received low-frequency TENS. Measures taken were initial claudication distance, functional claudication distance, and absolute claudication distance.

The Mc Gill Pain Questionnaire (MPQ) vocabulary was completed at the end of the intervention, and the MPQ-Pain Rating Index score was calculated. Four participants were excluded from the final analysis because of non-completion of the experimental procedure. Median walking distance increased with high-frequency TENS for all measures (p < 0.05, Wilcoxon signed rank test, all measures). Only absolute claudication distance increased significantly with low-frequency TENS compared with placebo (median of 179 to 228; Ws = 39; z = 2.025; p = 0.043; r = 0.48).

No difference was observed between reported median MPQ-Pain Rating Index scores: 21.5 with placebo TENS and 21.5 with active TENS (p = 0.41).

The authors concluded that TENS applied to the lower limb of the patients with PAD and IC was associated with increased walking distance on a treadmill; but not with any reduction in pain. They stated that TENS may be a useful adjunctive intervention to help increase walking performance in patients with IC. TENS for Post-Total Knee Arthroplasty Pain: Chughtai and associates (2016) noted that despite technological advances in total knee arthroplasty (TKA), management of post-operative muscle weakness and pain continue to pose challenges for both patients and health care providers.

Non-pharmacologic therapies, such as neuromodulation in the form of NMES and TENS, and other modalities, such as cryotherapy and pre-habilitation, have been highlighted as possible adjuncts to standard-of-care pharmacologic management to treat post-operative pain and muscle weakness.

These researchers discussed existing evidence for neuromodulation in the treatment of pain and muscular weakness following TKA, and shed light on other non-invasive and potential future modalities.

The review of the literature demonstrated that NMES, pre-habilitation, and some specialized exercises are beneficial for post-operative muscle weakness, and TENS, cooling therapies, and compression may help to alleviate post-TKA pain.

However, there are no clear guidelines for the use of these modalities. The authors concluded that further studies should be aimed at developing guidelines or delineating indications for neuromodulation and other non-pharmacologic therapies in the management of post-TKA pain and muscle weakness. TENS for Rotator Cuff Disease: In a Cochrane review, Page and colleagues (2016) synthesized available evidence regarding the benefits and harms of electrotherapy modalities for the treatment of people with rotator cuff disease.

These investigators searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid Medline (January 1966 to March 2015), Ovid Embase (January 1980 to March 2015), CINAHL Plus (EBSCOhost, January 1937 to March 2015), Clinical Trials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials.

They included RCTs and quasi-randomized trials, including adults with rotator cuff disease (e.g., calcific tendinitis, rotator cuff tendinitis, and subacromial impingement syndrome), and comparing any electrotherapy modality with placebo, no intervention, a different electrotherapy modality or any other intervention (e.g., glucocorticoid injection).

Trials investigating whether electrotherapy modalities were more effective than placebo or no treatment, or were an effective addition to another physical therapy intervention (e.g., manual therapy or exercise) were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events.

Two review authors independently selected trials for inclusion, extracted the data, performed a risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach.

These researchers included 47 trials (2,388 participants). Most trials (n = 43) included participants with rotator cuff disease without calcification (4 trials included people with calcific tendinitis); 16 (34 %) trials investigated the effect of an electrotherapy modality delivered in isolation. Only 23 % were rated at low risk of allocation bias, and 49 % were rated at low risk of both performance and detection bias (for self-reported outcomes).

The trials were heterogeneous in terms of population, intervention and comparator, so none of the data could be combined in a meta-analysis. In 1 trial (61 participants; low quality evidence), pulsed therapeutic US (3 to 5 times a week for 6 weeks) was compared with placebo (inactive US therapy) for calcific tendinitis. At 6 weeks, the mean reduction in overall pain with placebo was -6.3 points on a 52-point scale, and -14.9 points with US (MD -8.60 points, 95 % CI: -13.48 to -3.72 points; absolute risk difference 17 %, 7 % to 26 % more).

Mean improvement in function with placebo was 3.7 points on a 100-point scale, and 17.8 points with US (MD 14.10 points, 95 % CI: 5.39 to 22.81 points; absolute risk difference 14 %, 5 % to 23 % more); 91 % (29/32) of participants reported treatment success with US compared with 52 % (15/29) of participants receiving placebo (RR 1.75, 95 % CI: 1.21 to 2.53; absolute risk difference 39 %, 18 % to 60 % more). Mean improvement in quality of life with placebo was 0.40 points on a 10-point scale, and 2.60 points with US (MD 2.20 points, 95 % CI: 0.91 points to 3.49 points; absolute risk difference 22 %, 9 % to 35 % more).

Between-group differences were not important at 9 months. No participant reported adverse events.

Therapeutic US produced no clinically important additional benefits when combined with other physical therapy interventions (8 clinically heterogeneous trials, low quality evidence). The authors were uncertain whether there were differences in patient-important outcomes between US and other active interventions (manual therapy, acupuncture, glucocorticoid injection, glucocorticoid injection plus oral tolmetin sodium, or exercise) because the quality of evidence is very low; 2 placebo-controlled trials reported results favoring LLLT up to 3 weeks (low quality evidence), however combining LLLT with other physical therapy interventions produced few additional benefits (10 clinically heterogeneous trials, low quality evidence).

These researchers were uncertain whether TENS was more or less effective than glucocorticoid injection with respect to pain, function, global treatment success and active ROM because of the very low quality evidence from a single trial.

In other single, small trials, no clinically important benefits of PEMF, MENS, acetic acid iontophoresis and microwave diathermy were observed (low or very low quality evidence).

No adverse events of therapeutic US, LLLT, TENS or microwave diathermy were reported by any participants. Adverse events were not measured in any trials investigating the effects of PEMF, MENS or acetic acid iontophoresis. The authors concluded that based on low quality evidence, therapeutic US may have short-term benefits over placebo in people with calcific tendinitis, and LLLT may have short-term benefits over placebo in people with rotator cuff disease. They stated that further high quality placebo-controlled trials are needed to confirm these results.

In contrast, based on low quality evidence, PEMF may not provide clinically relevant benefits over placebo, and therapeutic US, LLLT and PEMF may not provide additional benefits when combined with other physical therapy interventions.

The authors were uncertain if TENS is superior to placebo, and whether any electrotherapy modality provides benefits over other active interventions (e.g., glucocorticoid injection) because of the very low quality of the evidence. They stated that practitioners should communicate the uncertainty of these effects and consider other approaches or combinations of treatment. The authors stated that further trials of electrotherapy modalities for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

Desmeules et al (2016) performed a systematic review on the effectiveness of TENS for the treatment of rotator cuff tendinopathy in adults.

A literature search was conducted in 4 databases (CINAHL, Embase, Pub Med and Pe DRO) for RCTs published from date of inception until April 2015, comparing the effectiveness of TENS for the treatment of rotator cuff tendinopathy with placebo or any other intervention.

Risk of bias was evaluated using the Cochrane risk of bias tool; results were summarized qualitatively. A total of 6 studies were included in this review. The mean methodological score was 49 % (standard deviation 16 %), indicating an overall high risk of bias. One placebo-controlled trial reported that a single TENS session provided immediate pain reduction for patients with rotator cuff tendinopathy, but did not follow the participants in the short-, medium- or long-term.

Two trials that compared US therapy with TENS reported discrepancy and contradictory results in terms of pain reduction and shoulder ROM. Corticosteroid injections were found to be superior to TENS for pain reduction in the short-term, but the differences were not clinically important.

Other studies included in this review concluded that TENS was not superior to heat or pulsed radiofrequency.

The authors concluded that due to the limited number of studies and the overall high risk of bias of the studies included in this review, no conclusions can be drawn on the effectiveness of TENS for the treatment of rotator cuff tendinopathy.

They stated that more methodologically sound studies are needed to document the effectiveness of TENS; until then, clinicians should prefer other evidence-based rehabilitation interventions proven to be effective to treat patients with rotator cuff tendinopathy. TENS for Chemotherapy-Induced Peripheral Neuropathy: In a double-blind, randomized and placebo-controlled study, Tonezzer and associates (2017) examined the effects of TENS for reducing the side effects of chemotherapy-induced peripheral neuropathy (CIPN) in cancer patients undergoing chemotherapy with oxaliplatin or paclitaxel.

A total of 24 patients were randomly allocated into 2 groups:active or (placebo stimulation. All patients were evaluated for pain, numbness/tingling, frequency of symptoms, and quality of life. The TENS device was applied daily with modulating frequencies ranging between 7-Hz and 65-Hz in distal limb regions during 3 cycles of chemotherapy (45 days). The other stimulation parameters were: pulse duration of 200 μsec, intensity at the highest tolerable level, and increases in intensity when it diminished.

The data showed no difference between active or placebo groups in terms of pain, numbness/tingling, frequency of symptoms or impact on daily life activities. The authors concluded that these results suggested that TENS applied in the frequency variation mode was not proven to be effective to improve the symptoms of CIPN during chemotherapy cycles.

There was no worsening of symptoms in subsequent cycles of the onset of symptoms of the disease. TENS for Fibromyalgia: In a Cochrane review, Johnson and colleagues (2017) evaluated the effectiveness and adverse events of TENS alone or added to usual care (including exercise) compared with placebo (sham) TENS; no treatment; exercise alone; or other treatment including medication, electro-acupuncture, warmth therapy, or hydrotherapy for fibromyalgia in adults.

These investigators searched the following electronic databases up to January 18, 2017: CENTRAL (CRSO); Medline (Ovid); Embase (Ovid); CINAHL (EBSCO); Psyc INFO (Ovid); LILACS; PEDRO; Web of Science (ISI); AMED (Ovid); and SPORTDiscus (EBSCO).

They also searched 3 trial registries. There were no language restrictions. These researchers included RCTs or quasi-randomized trials of TENS treatment for pain associated with fibromyalgia in adults.

They included cross-over and parallel-group trial designs. They included studies that evaluated TENS administered using non-invasive techniques at intensities that produced perceptible TENS sensations during stimulation at either the site of pain or over nerve bundles proximal (or near) to the site of pain.

The authors included TENS administered as a sole treatment or TENS in combination with other treatments, and TENS given as a single treatment or as a course of treatments. Two review authors independently determined study eligibility by assessing each record and reaching agreement by discussion. A 3rd review author acted as arbiter. These researchers did not anonymize the records of studies before assessment.

Two review authors independently extracted data and assessed risk of bias of included studies before entering information into a “Characteristics of included studies” table. Primary outcomes were participant-reported pain relief from baseline of 30 % or greater or 50 % or greater, and Patient Global Impression of Change (PGIC).

These investigators assessed the evidence using GRADE and added “Summary of findings” tables. The authors included 8 studies (7 RCTs, 1 quasi-RCT, 315 adults (299 women), aged 18 to 75 years): 6 used a parallel-group design and 2 used a cross-over design. Sample sizes of intervention arms were 5 to 43 subjects. Two studies, 1 of which was a cross-over design, compared TENS with placebo TENS (82 participants), 1 study compared TENS with no treatment (43 subjects), and 4 studies compared TENS with other treatments (medication (2 studies, 74 participants), electro-acupuncture (1 study, 44 participants), superficial warmth (1 cross-over study, 32 subjects), and hydrotherapy (1 study, 10 participants)).

Two studies compared TENS plus exercise with exercise alone (98 participants, 49 per treatment arm).

None of the studies measured participant-reported pain relief of 50 % or greater or PGIC. Overall, the studies were at unclear or high risk of bias, and in particular all were at high risk of bias for sample size.

Only 1 study (14 participants) measured the primary outcome participant-reported pain relief of 30 % or greater; 30 % achieved 30 % or greater reduction in pain with TENS and exercise compared with 13 % with exercise alone. One study found 10/28 participants reported pain relief of 25 % or greater with TENS compared with 10/24 participants using superficial warmth (42 °C). These researchers judged that statistical pooling was not possible because there were insufficient data and outcomes were not homogeneous.

There were no data for the primary outcomes participant-reported pain relief from baseline of 50 % or greater and PGIC. There was a paucity of data for secondary outcomes. One pilot cross-over study of 43 subjects found that the mean (95 % CI) decrease in pain intensity on movement (100-mm VAS) during one 30-min treatment was 11.1 mm (95 % CI: 5.9 to 16.3) for TENS and 2.3 mm (95 % CI: 2.4 to 7.7) for placebo TENS.

There were no significant differences between TENS and placebo for pain at rest. One parallel group study of 39 participants found that mean ± standard deviation (SD) pain intensity (100-mm VAS) decreased from 85 ± 20 mm at baseline to 43 ± 20 mm after 1 week of dual-site TENS; decreased from 85 ± 10 mm at baseline to 60 ± 10 mm after single-site TENS; and decreased from 82 ± 20 mm at baseline to 80 ± 20 mm after 1 week of placebo TENS.

The authors of 7 studies concluded that TENS relieved pain but the findings of single small studies are unlikely to be correct. One study found clinically important improvements in Fibromyalgia Impact Questionnaire (FIQ) subscales for work performance, fatigue, stiffness, anxiety, and depression for TENS with exercise compared with exercise alone. One study found no additional improvements in FIQ scores when TENS was added to the first 3 weeks of a 12-week supervised exercise program. No serious adverse events were reported in any of the studies although there were reports of TENS causing minor discomfort in a total of 3 participants.

The quality of evidence was very low. These investigators down-graded the GRADE rating mostly due to a lack of data; thus, they had little confidence in the effect estimates where available. The authors concluded that there was insufficient high-quality evidence to support or refute the use of TENS for fibromyalgia.

They found a small number of inadequately powered studies with incomplete reporting of methodologies and treatment interventions. TENS for Musculoskeletal Pain in Hemophilia: Rodriguez-Merchan (2017) noted that musculoskeletal pain treatment is inadequate in many hemophilic patients.

Analgesics are used only by 36 % of adult patients. FVIII/FIX intravenous infusion is mainly used to lessen pain, followed in frequency by usage of NSAIDS (primarily COX-2 inhibitors). In about 30 % of patients, pain continues after infusion of F VIII/IX. In acute hemarthroses pain treatment must continue until total disappearance (checked by ultrasonography) and include hematologic treatment, short-term rest of the involved joint, cryotherapy, joint aspiration and analgesic medication (paracetamol in mild pain, metamizole for more intense pain, and in a few precise patients, soft opioids such as codeine or tramadol).

In the circumstance of intolerable pain these investigators use morphine hydrochloride either by continual infusion or a patient-controlled analgesia (PCA) pump, determined by the age, mental condition and grade of observance of the patient.

Epidural blocks utilizing bupivacaine and fentanyl may be very effective as well. Three main strategies to alleviate chronic musculoskeletal pain secondary to hemophilic arthropathy (joint degeneration) exist:pharmacologic management,physical medicine and rehabilitation, and intra-articular injections. As for pharmacologic management, NSAIDs (ibuprofen, diclofenac, celecoxib, robecoxib) are better than paracetamol.

The advantages of tramadol or tramadol/paracetamol and non-tramadol opioids are scanty. With respect to physical medicine and rehabilitation, there is insufficient confirmation that a brace has supplementary favorable effect compared with isolated pharmacologic management. Land-based curative exercise and watery exercise have at the minimum a tiny short-run benefit. Curative ultrasound can be helpful (poor quality of evidence).

The effectiveness of TENS for pain mitigation has not been proven. Electrical stimulation treatment can procure notable ameliorations. With respect to intra-articular injections, viscosupplementation appears to be a useful method for pain alleviation in the short-run (months). The short-run (weeks) advantage of intra-articular corticosteroids in the treatment of joint pain has been shown.

Interferential Stimulation: Interferential stimulation (IFS) is characterized by 2 alternating-current sine waves of differing frequencies that ""work"" together to produce an interferential current that is also known as a beat pulse or alternating modulation frequency.

One of the 2 currents is usually held at 4,000 Hz, and the other can be held constant or varied over a range of 4,001 to 4,100 Hz. Interferential currents reportedly can stimulate sensory, motor, and pain fibers. Because of the frequency, the interferential wave meets low impedance when crossing the skin to enter the underlying tissue.

This deep tissue penetration can be adjusted to stimulate parasympathetic nerve fibers for increased blood flow. According to proponents, interferential stimulation differs from TENS because it allows a deeper penetration of the tissue with more comfort (compliance) and increased circulation.

It has been claimed that IFS is highly effective in reducing:pain and use of pain medications, edema and inflammation, and healing time, as well as in improvin range of motion, and activity levels, and quality of life. However, there are very few well designed studies such as randomized, double blind, controlled clinical trials that support such claims.

Low (1988) stated that in spite of widespread agreement among physiotherapists that IFS has a marked pain relieving effect, there is a paucity of objective investigations into this analgesic effect. He claimed that both the therapeutic and physiological effects of interferential currents require further investigation. This notion is echoed by Goats (1990) who reported that evidence supporting the use of IFS in the control of edema appears mainly anecdotal.

Reitman and Esses (1995) noted that there were no controlled studies proving the effectiveness of IFS. Indergand and Morgan (1995) reported that interferential current applied over the stellate ganglion did not change forearm hemodynamics in asymptomatic individuals. The authors stated that these findings challenged the concept that IFS can block sympathetic vasoconstrictor impulses in peripheral nerves.

In a randomized placebo controlled study, Van Der Heijden et al (1999) evaluated the effectiveness of bipolar interferential electrotherapy (ET) and pulsed ultrasound (US) as adjuvants to exercise therapy for soft tissue shoulder disorders (n = 180). Patients with shoulder pain and/or restricted shoulder mobility, because of soft tissue impairment without underlying specific or generalized condition, were randomised to receive:active ET plus active US; active ET plus dummy US; dummy ET plus active US; dummy ET plus dummy US; or no adjuvants.

Additionally, they received a maximum of 12 sessions of exercise therapy in 6 weeks. Measurements at baseline, 6 weeks and 3, 6, 9, and 12 months later were blinded for treatment. Outcome measures: recovery, functional status, chief complaint, pain, clinical status, and range of motion.

At the 6th-week, 7 patients (20 %) without adjuvants reported very large improvement (including complete recovery), 17 (23 %) and 16 (22 %) with active and dummy ET, and 19 (26 %) and 14 (19 %) with active and dummy US.

These proportions increased to about 40 % at the 3rd-months, but remained virtually stable thereafter. The authors concluded that neither ET nor US proved to be effective as adjuvants to exercise therapy for soft tissue shoulder disorders.

Jarit et al (2003) concluded that home IFS may help reduce pain, pain medication taken, and swelling while increasing range of motion in patients undergoing knee surgery. This could result in quicker return to activities of daily living and athletic activities. Drawbacks of this study were as follows:while placebo subjects did consume more medications at all time points, the difference was only at some points, anda functional assessment scale was not used.

The findings of this study need to be validated by further investigation. Furthermore, a technology assessment by the California Technology Assessment Forum (CTAF, 2005) concluded that interferential stimulation does not meet CTAF’s assessment criteria.

A review on non-pharmacological therapies (including IFS) for acute and chronic LBP by the American Pain Society and the American College of Physicians (Chou et al, 2007) concluded that therapies with good evidence of moderate efficacy for chronic or sub-acute LBP are cognitive-behavioral therapy, exercise, spinal manipulation, and inter-disciplinary rehabilitation.

For acute LBP, the only therapy with good evidence of efficacy is superficial heat. Guidelines on treatment of LBP from the National Collaborating Centre for Primary Care (Savigny et al, 2009) found insufficient evidence for the use of interferential stimulation in LBP and recommended against its use for that indication. In a systematic review and meta-analysis, Fuentes et al (2010) analyzed the available information regarding the efficacy of IFS in the management of musculoskeletal pain. Randomized controlled trials were obtained through a computerized search of bibliographic databases (i.e., CINAHL, Cochrane Library, EMBASE, MEDLINE, PEDro, Scopus, and Web of Science) from 1950 to February 8, 2010.

Two independent reviewers screened the abstracts found in the databases. Methodological quality was assessed using a compilation of items included in different scales related to rehabilitation research. The mean difference, with 95 % confidence interval (CI), was used to quantify the pooled effect. A chi-square test for heterogeneity was performed. A total of 2,235 articles were found. A total of 20 studies fulfilled the inclusion criteria; 7 articles assessed the use of IFS on joint pain; 9 articles evaluated the use of IFS on muscle pain; 3 articles evaluated its use on soft tissue shoulder pain; and 1 article examined its use on post-operative pain.

Three of the 20 studies were considered to be of high methodological quality, 14 studies were considered to be of moderate methodological quality, and 3 studies were considered to be of poor methodological quality.

Fourteen studies were included in the meta-analysis. The authors concluded that IFS as a supplement to another intervention seems to be more effective for reducing pain than a control treatment at discharge and more effective than a placebo treatment at the 3-month follow-up. However, it is unknown whether the analgesic effect of IFS is superior to that of the concomitant interventions. Interferential current alone was not significantly better than placebo or other therapy at discharge or follow-up.

Results must be considered with caution due to the low number of studies that used IFS alone. In addition, the heterogeneity across studies and methodological limitations prevent conclusive statements regarding analgesic efficacy. Percutaneous Electrical Nerve Stimulation (PENS): Percutaneous electrical nerve stimulation uses acupuncture-like needles as electrodes. These needles are placed in the soft tissues or muscles at dermatomal levels corresponding to local pathology (needles are usually inserted above and below and into the central area of pain). A 5-Hz frequency with a pulse width of 0.5 m S is usually used. If relief is not attained within 15 minutes, the frequency may be lowered to 1 Hz.

According to PENS proponents, the main advantage of PENS over TENS is that it bypasses the local skin resistance and delivers electrical stimuli at the precisely desired level in close proximity to the nerve endings located in soft tissue, muscle, or periosteum of the involved dermatomes.

Percutaneous electrical nerve stimulation has also been used in the treatment of neck pain; however, there is insufficient evidence to support its effectiveness for this indication. Harris and Susman (2002) stated that the Philadelphia Panel recently formulated evidence-based guidelines for selected rehabilitation interventions in the management of low back, knee, neck, and shoulder pain. The guidelines were developed with the use of a 5-step process:define the intervention, collect evidence, synthesize results, make recommendations based on the research, andgrade the strength of the recommendations.

Outpatient adults with low back, knee, neck, or shoulder pain without vertebral disk involvement, scoliosis, cancer, or pulmonary, neurological, cardiac, dermatological, or psychiatric conditions were included in the review.

To prepare the data, systematic reviews were performed for low back, knee, neck, and shoulder pain. Therapeutic exercise, massage, transcutaneous electrical nerve stimulation, thermotherapy, ultrasound, electrical stimulation, and combinations of these therapies were included in the literature search. Studies were identified and analyzed based on study type, clinical significance, and statistical significance.

The authors concluded that the Philadelphia Panel guidelines recommend continued normal activity for acute, uncomplicated LBP and therapeutic exercise for chronic, subacute, and post-surgical LBP; TENS and exercise for knee osteoarthritis; proprioceptive and therapeutic exercise for chronic neck pain; and the use of therapeutic ultrasound in the treatment of calcific tendonitis of the shoulder. Weiner and Ernst (2004) reviewed common complementary and alternative treatment modalities for the treatment of persistent musculoskeletal pain in older adults.

A critical review of the literature on acupuncture and related modalities, herbal therapies, homeopathy, and spinal manipulation was carried out. Review included 678 cases within 21 randomized trials and 2 systematic reviews of herbal therapies: 798 cases within 2 systematic reviews of homeopathy; 1,059 cases within 1 systematic review of spinal manipulation for LBP, and 419 cases within 4 randomized controlled trials for neck pain.

The review of acupuncture and related modalities was based upon a paucity of well-controlled studies combined with the authors' clinical experience. Insufficient experimental evidence exists to recommend the use of traditional Chinese acupuncture over other modalities for older adults with persistent musculoskeletal pain.

Promising preliminary evidence exists to support the use of percutaneous electrical nerve stimulation for persistent LBP. The authors noted that while the use of complementary and alternative modalities for the treatment of persistent musculoskeletal pain continues to increase, rigorous clinical trials examining their effectiveness are needed before definitive recommendations regarding the application of these modalities can be made.

A Cochrane review on electrotherapy for mechanical neck disorders (Kroeling et al, 2005) evaluated if electrotherapy relieves pain or improves function/disability in adults with mechanical neck disorders (MND). For the pain outcome, there was limited evidence of benefit, i.e., pulsed electromagnetic field (PEMF) therapy resulted in only immediate post-treatment pain relief for chronic MND and acute whiplash (WAD).

Other findings included unclear or conflicting evidence (galvanic current for acute or chronic occipital headache; iontophoresis for acute, subacute WAD; TENS for acute WAD, chronic MND; PEMF for medium- or long-term effects in acute WAD, chronic MND); and limited evidence of no benefit (diadynamic current for reduction of trigger point tenderness in chronic MND, cervicogenic headache; permanent magnets for chronic MND; electrical muscle stimulation (EMS) for chronic MND).

The authors concluded that in pain as well as other outcomes, the evidence for treatment of acute or chronic MND by different forms of electrotherapy is either lacking, limited, or conflicting.

The National Institute for Health and Clinical Excellence’s assessment on “Percutaneous electrical nerve stimulation for refractory neuropathic pain” (NICE, 2013) stated that “Current evidence on the safety of percutaneous electrical nerve stimulation (PENS) for refractory neuropathic pain raises no major safety concerns and there is evidence of efficacy in the short term. Therefore this procedure may be used with normal arrangements for clinical governance, consent and audit”.

Fraser and Woodbury (2017) stated that fibromyalgia and complex regional pain syndrome (CRPS) are both chronic pain syndromes with pathophysiologic mechanisms related to autonomic nervous system (ANS) dysregulation and central sensitization.

Both syndromes are considered difficult to treat with conventional pain therapies. These investigators described a female veteran with fibromyalgia and a male veteran with CRPS, both of whom failed multiple pharmacologic, physical and psychological therapies for pain, but responded to percutaneous electrical neural field stimulation (PENFS) targeted at the auricular branches of the cranial nerves.

The authors concluded that while PENFS applied to the body has been previously described for treatment of localized pain, PENFS effects on cranial nerve branches of the ear was not well-known, particularly when used for regional and full-body pain syndromes such as those described here. They stated that PENFS of the ear is a minimally-invasive, non-pharmacologic therapy that could lead to improved quality of life (QOL) and decreased reliance on medication. However, they stated that ffurther research is needed to guide clinical application, particularly in complex pain patients.

Percutaneous Neuromodulation: Percutaneous neuromodulation therapy (PNT) is a variation of PENS, but utilizes different electrical impulses than PENS; it utilizes an alternating low and high frequency current at varying pulse impulses (Washington State Department of Labor and Industries, 2004). The electrical stimulation is delivered via needle-like electrodes which is purported to allow the stimulation to reach the deep tissue.

Examples of this type of device include, but may not be limited to, the Vertis PNT System and the Bio Wave PRO Neuromodulation Pain Therapy System.

The Vertis PNT is for treatment of back pain; the Bio Wave PRO, however, is not limited to the spine but may also be used in other painful areas in the body. These devices are not for home use, but must be used by a healthcare provider, such as a physician or physical therapist, in a clinic or office setting. Kang, et al. (2007) reported on a single-blinded pilot randomized controlled trial in 70 patients with knee osteoarthritis who were randomized to a Bio Wave Deepwave percutaneous neuromodulation device or to sham administered in a clinic over 30 minutes.

Seven subjects assigned to sham were lost to followup. Pain intensity difference was the primary measure of efficacy in this trial. Pain intensity difference was defined as the difference in visual analog pain scale noted at pretreatment (baseline) versus the visual analog pain scale noted at each post-treatment period.

The active group's pain intensity difference was statitically significantly greater than the sham group’s pain intensity difference by 9.5 mm immediately after treatment.

The active group's pain intensity difference was also greater than the sham group's pain intensity difference by 5.0 mm, 9.0 mm, and 7.0 mm for the 6-, 24-, and 48-hour post-treatment periods, respectively, although the pain intensity difference was not statistically significant at these time points. Additionally, a nonsignificant trend was noted in improvement of the pain intensity difference in the live group as compared to the sham group 48 hours post-treatment.

Limitations of this pilot study include single blinding, lack of testing of adequacy of blinding, and lack of intention-to-treat analysis.

The authors concluded: ""The results from this pilot phase may be used to design a broader multicenter study that will be powered to provide greater data points leading to broader conclusions as to the treatment efficacy of the percutaneous Deepwave device.

""Peripherally Implanted Nerve Stimulation: In this particular treatment, an electrical current is transmitted via an electrode that has been implanted around the selected peripheral nerve. This electrical current purports to block or disrupt the normal transmission of pain signals. The electrodes are connected by a wire to the peripherally implanted neurostimulator (also known as an implantable subcutaneous target stimulator). An external generator (similar to a remote control device) controls the degree of stimulation the individual receives.

In an industry funded study, Deer, et al. (2016) reported on a crossover study of 94 patients with pain of peripheral origin were implanted and then randomized to the treatment with peripheral nerve stimulation (45) or the control group (49).

The primary efficacy endpoint was response rate, defined as a 30 percent decrease in a numerical rating scale, with no upward titration in the patient's medication regimen, three months months after randomization to treatment. The investigators reported that patients receiving active stimulation achieved a statistically significantly higher response rate of 38% versus the 10% rate found in the control group (p = 0.0048).

Improvement in pain was statistically significant between the randomized groups, with the treatment group achieving a mean pain reduction of 27.2% from baseline to month 3 compared to a 2.3% reduction in the control group (p < 0.0001). During the partial crossover period, patients again demonstrated statistically significant improvement in pain relief with active stimulation compared to baseline.

Further, the treatment group had significantly better improvement than the control group in secondary measures including but not limited to quality of life and satisfaction. Safety, assessed throughout the trial and with follow-up to one year, demonstrated no serious adverse events related to the device. The investigators reported that all device-related adverse events were minor and self-limiting. Additional studies confirming these benefits are needed.

Peripheral Subcutaneous Field Stimulation: Subcutaneous stimulation (peripheral nerve field stimulation/PNFS) is a novel neuromodulation modality that has increased in its utilization during the past decade. It consists of introducing a lead in the subdermal level to stimulate the small nerve fibers in that layer.

Unlike other neuromodulation techniques including direct peripheral nerve stimulation, spinal cord stimulation (SCS), or deep brain stimulation, the precise target is not identified. Falco et al (2009) stated that relief of regional, non-appendicular pain, particularly LBP, through SCS has proven challenging.

Recently, peripheral nerve stimulation (PNS), also known as PNFS depending on the stimulation area, has demonstrated efficacy for the treatment of well-localized, small areas of pain involving the abdomen, inguinal region, pelvis, face, occipital area, and low back.

More widespread application of PNFS has been limited by its narrow field of coverage in a larger group of patients with diffuse or poorly localized pain.

Mc Roberts and Roche (2010) described a novel approach for the treatment of severe, chronic knee joint pain following total knee arthroplasty utilizing peripheral subcutaneous field stimulation (PSFS) and discussed the role of this treatment modality in patients with symptoms that are refractory to conventional pharmacologic, surgical, and physical therapies. These researchers presented 2 case reports of patients with chronic intractable knee pain where PNS via a permanent neurostimulating implant was introduced successfully. Both patients presented with persistent knee pain, for greater than 1 year, after having had total knee arthroplasty. Their symptoms failed to be alleviated by a variety of interventions including NSAIDS, oral anti-depressants, membrane stabilizers, opioids, physical therapy, surgical revisions, manipulation under anesthesia, local anesthetic patches, and TENS.

In each case, direct stimulation of the knee was achieved utilizing a peripheral nerve stimulator via a peri-articular approach. Neuromodulation daily has produced both significant pain relief and functional improvement. Significant decreases in VAS pain scores and improvement in functional capacity were observed during the stimulation trial and during the follow-up after permanent implantation.

The mean VAS score changed dramatically. The authors concluded that introduction of PSFS directly to the painful knee area is a novel and simple procedure that was extremely effective for the relief of pain and may provide a breakthrough in the treatment of chronic intractable knee pain following total knee arthroplasty. The peri-articular approach has several advantages, including only small incisions over the lateral and medial knee, proximal thigh and abdomen resulting in minimal strain on the lead array with flexion and extension contributing to overall stability of this system.

Yakovlev and Resch (2010) presented a case report describing application of PSFS to a patient with chronic intractable atypical facial pain (ATFP) that conventional treatment failed to ameliorate.

The patient underwent an uneventful PSFS trial with percutaneous placement of 2 temporary 8-electrode leads (Medtronic Inc, Minneapolis, MN) placed subdermally over the left mandible. After experiencing excellent pain relief over the next 2 days, the patient was implanted with permanent leads and rechargeable generator 2 and a half weeks later and reported sustained pain relief at 12-month follow-up visit. Peripheral subcutaneous field stimulation provides an effective treatment option for patients suffering from chronic ATFP who have failed conservative treatment.

The authors concluded that PSFS offers an alternative treatment option to select patients with intractable ATFP. In a retrospective study, Yakovlev et al (2010) evaluated the effectiveness of PSFS for the treatment of chronic hip pain after total hip arthroplasty (THA) and greater trochanteric bursectomy (GTB).

A total of 12 patients with chronic post-operative pain after THA and GTB underwent an uneventful PSFS trial with percutaneous placement of 2 temporary 8-electrode leads positioned in the subcutaneous tissue in the area of greatest pain, parallel to post-operative scar over the affected upper lateral thigh. After experiencing excellent pain relief over the next 2 days, the patients were implanted with permanent leads and rechargeable or non-rechargeable generator 2 to 4 weeks later.

They reported sustained pain relief at 12-month follow-up visits. The authors concluded that PSFS provided an effective alternative treatment option for select patients with chronic post-operative pain after THA and GTB who have failed conservative treatment.

Ricciardo et al (2010) presented a case study to exemplify the application of PSFS in the treatment of recalcitrant notalgia paraesthetica. The patient was a 60-year old woman with severe and disabling notalgia paraesthetica. The itch persisted despite the use of several medications -- topical and oral. Following a successful trial of PSFS with a temporary electrode, 2 subcutaneous electrodes were inserted into the affected area with a battery implanted subcutaneously in her right buttock. The patient was reviewed at 5 months post-implantation. She reported a greater than 85 % improvement in her itch.

She also reported a major improvement in her quality of life, with particular improvement in her ability to sleep through the night. This case illustrated the possible utilization of PSFS in the treatment of notalgia paraesthetica, which is a common yet poorly understood and treated condition.

The authors stated that replication and controlled studies are needed to determine the general applicability of this approach. Goroszeniuk et al (2012) reported the use of an alternative approach to neuromodulation of anginal pain using subcutaneous leads placed at the site of pain.

In this case series, 5 patients with refractory angina received successful treatment with subcutaneous target stimulation -- peripheral subcutaneous field stimulation. This technique was able to provide good analgesia in 2 patients that had had poor pain relief from existing spinal cord stimulators. All 5 patients achieved significant pain relief with a reduction in symptoms and a decrease in the use of pain medication.

Burgher et al (2012) performed a retrospective review of consecutive patients evaluated from August 2009 to December 2010 who had undergone trial of subcutaneous (SQ) PNS with inter-lead stimulation for axial spine pain. Patients proceeding to implant were followed post-operatively with routine clinical visits and a survey form at last follow-up. Ultrasound was used intra-operatively to ensure placement of electrodes at the appropriate depth in patients with larger body mass index.

Primary outcome was patient-reported pain relief at last follow-up. Literature review was conducted by searching MEDLINE (1948 to present) and through an unstructured review by the authors.

A total of 10 patients underwent trial of SQ PNS and 6 proceeded to permanent implantation; 3 of the 6 (50 %) implanted patients preferred neurostimulation programming that included inter-lead stimulation (""cross-talk""). Average duration of post-operative follow-up was 4.5 months (range of 2 to 9 months). Average patient-reported pain relief at last follow-up was 45 % (range of 20 to 80 %). One patient required re-operation for migration. Patients not proceeding to implant had paresthesia coverage but no analgesia.

The authors concluded that SQ PNS is a promising therapy for axial neck and back pain based on a small cohort of patients. Ultrasound was useful to assist with electrode placement at the most appropriate depth beneath the skin. While inter-lead stimulation has been preferred by patients in published reports, these investigators did not find it clearly influenced pain relief. The authors stated that future investigations should include a randomized, controlled study design, as well as defined implantation technique and neurostimulator programming algorithms.

H-Wave Stimulation: H-Wave stimulation is a form of electrical stimulation that differs from other forms of electrical stimulation in terms of its waveform.

The H-wave produces low frequency muscle stimulation and high frequency pain control. H-wave stimulation has been purported for use in pain control for conditions such as complex regional pain syndrome (reflex sympathetic dystrophy), muscle sprains, temporomandibular joint dysfunctions or treatment of diabetic neuropathy. H-wave stimulation delivers electrical stimulation in the form of milliamperage. H-wave stimulation is intended to emulate the H waveform found in nerve signals (Hoffman Reflex) and therefore enables greater and deeper penetration of a low frequency current, while using significantly less power than other machines.

This allegedly makes H-Wave stimulation much safer, less painful and more effective than other forms of electrotherapy to date.

The H-wave signal is a bipolar, exponential decaying waveform that supposedly overcomes the disadvantages of other electrotherapy machines. It allows the therapist to apply 2 treatments at the same time:low-frequency muscle stimulation and high-frequency deep analgesic pain control (a ""TENS"" effect).

Note: H-wave stimulation must be distinguished from the H-waves that are a component of electromyography. The H-wave stimulator (Electronic Waveform Lab, Inc., Huntington Beach, CA) is an electrostimulation device that has been used to reduce pain and swelling associated with a variety of diseases and conditions.

In a single-blinded clinical study, Kumar and Marshall (1997) evaluated the effectiveness of H-wave stimulation for the treatment of chronic (greater than 2 months) pain associated with diabetic (type 2) peripheral neuropathy (n = 31). Patients were randomly assigned to: H-wave stimulation, or sham treatment. The authors reported that H-wave treated patients exhibited greater symptomatic relief than their sham-treated counterparts.

Moreover, it has also been shown that H-wave stimulation may be a useful adjunctive modality when combined with pharmacotherapy (e.g., amitriptyline) to augment symptomatic relief in patients with diabetic peripheral neuropathy (Julka et al, 1998; Mc Dowell et al, 1999). On the other hand, H-wave stimulators have not been shown to be effective in reducing pain from causes other than chronic diabetic peripheral neuropathy, or in reducing edema or swelling.

In particular, H-wave stimulation has not been demonstrated to be effective in treating chronic pain due to ischemia. In the study by Kumar and Marshall (1997), patients with significant peripheral vascular disease were excluded from the trial.

Furthermore, in a randomized controlled study (n = 112), Mc Dowell et al (1995) reported that H-wave stimulation was not effective in reducing experimental ischemic pain. A systematic evidence review concluded that H-wave stimulation had a moderate to strong effects in relieving pain, reducing pain medication use and increasing functionality in patients with chronic soft tissue inflammation or neuropathic pain (Blum et al, 2008).

A critique of this systematic evidence review by the Centre for Reviews and Dissemination (CRD, 2009) concluded that ""it is not possible to determine whether the results of this review are reliable"" given its significant methodologic limitations.

In particular, very limited details of the included studies were given in the review; in particular it was unclear which studies were randomized, no control interventions were detailed, and there were insufficient details on the outcome measures used.

Although a validity assessment was performed, the results were not presented. ""Given these omissions, it is difficult to assess either the internal or external validity of the results."" The CRD noted that the authors of the systematic evidence review used meta-analysis to combine the results, but different measures of effect appeared to be combined in a single effect size.

Insufficient details on the outcome measures used in the included studies meant that it was not possible to determine if this was appropriate or not.

The CRD critique noted that, in addition to four authors of the systematic evidence review being independent consultants for Electronic Waveform Lab (the makers of the H-Wave device), 2 authors were members of the research groups responsible for conducting the primary studies. Intramuscular Stimulation: Intramuscular stimulation can be considered as a variation of acupuncture.

It has been claimed to promote long-term relief in chronic neuropathic pain. Intramuscular stimulation utilizes the same sized needles as in acupuncture; they are inserted into the part of a shortened muscle where a nerve may be entrapped. This most often causes some local pain as the needle is re-inserted several times to release the nerve and lengthen the muscle.

In general, treatments are administered once or twice weekly for 3 to 6 weeks. However, the clinical value of this invasive procedure has not been validated by randomized controlled studies. Sympathetic Therapy (Dynatron): Many chronic pain syndromes/conditions (e.g., peripheral neuropathies and reflex sympathetic dystrophy) are ""sympathetically biased"" and have no identifiable underlying cause (s).

Sympathetic Therapy is a non-invasive treatment protocol advocated for the symptomatic relief of patients with chronic pain. It is a patented method of delivering electrostimulation via peripheral nerves to create a ""special"" form of stimulation of the sympathetic nervous system. It incorporates dual interfering waveforms with specific electrode placement on the upper and lower extremities (8 electrodes/treatment).

Electrodes are placed bilaterally over dermatomes, thus accessing the autonomic nervous system via the peripheral nervous system. The treatment plan for Sympathetic Therapy includes clinical treatments followed by home therapy. Electrostimulation is administered by means of the Dynatron STS (a clinical unit) or the Dynatron STS Rx (a home unit).

A software program is included with the clinical Dynatron unit to help doctors with electrode placement and to record patient progress. According to the manufacturer, electrostimulation delivered by the Dynatron is different from that provided by TENS. The key difference is in its application -- Dynatron applied within the Sympathetic Therapy protocol supposedly treats systemically while TENS treats transcutaneously at or near the primary pain location.

Daily therapy sessions are needed to establish effectiveness of the treatment and to ascertain the most effective protocol for individual patients (20 or more sessions may be needed to complete this process). Each treatment session lasts about 60 mins. If the patient responds to treatment and the optimal protocol has been established, a home Dynatron unit may be prescribed to facilitate treatments over an extended period of time and, in most cases, indefinitely.

If necessary, the patient may return to the clinic periodically for a follow-up visit to adjust the protocol or receive additional guidance in administering home therapy. Guido (2002) reported on the effects of Sympathetic Therapy on 20 patients with chronic pain and peripheral neuropathies.

Subjects were treated daily with the Dynatron STS for 28 days. At the beginning of the study, 11 of 15 patients reported being in moderate to severe pain, whereas by the end of treatment, 5 of 15 patients defined their pain as being moderate to severe. For these 15 patients, mean cumulative VAS for multiple locations of pain decreased significantly, from 107.8 to 45.3.

(The authors stated, without further explanation, that self-reports of pain severity were unavailable for 5 of the 20 patients.) However, because the study did not include a randomized masked control group, placebo effects and other biases could affect results.

In addition, the lack of data on pain severity in a quarter of the patients included in this study may have significantly biased the results. There are no published randomized controlled clinical trials of the effectiveness of Sympathetic Therapy in the management of patients with chronic intractable pain. Randomized controlled trials are needed to ascertain the clinical benefits of this treatment protocol in these patients.

An assessment (2003) conducted by the Washington State Department of Labor and Industries concluded that insufficient evidence exists to determine Dynatron STS’ effectiveness in the treatment of chronic pain. Guidelines on management of chronic pain from the Work Loss Data Institute (2008) considered, but did not recommend, sympathetic therapy for chronic pain.

Electroceutical Therapy: Electroceutical therapy is a noninvasive device that uses a variety of electrical modalities as a proposed treatment for acute and chronic pain. The device is similar to TENS, except electroceutical treatments use higher electrical frequencies, altering the electric current to mimic the human bioelectric system. This therapy may also be referred to as bioelectric nerve block, noninvasive neuron blockade, electroceutical neuron blockade and bioelectric treatment system.

An example of this is the Hako-Med Pro Elect DT 2000. Electroceutical medicine entails the use of various electrical modalities. While certain ""low-strength"" electrical treatments such as transcutaneous electrical nerve stimulation (TENS) units may be safely used at home, electroceutical treatments use much higher electrical frequencies than TENS units (ranging from 1 to 20,000 Hz compared to 0.5 to 100 Hz used in TENS) and may only be prescribed and administered under the supervision of a healthcare provider experienced in this method of treatment.

Electroceutical therapy, also known as bioelectric nerve block, involves blockade of axonal transmissions. Electroceutical therapy has been used in the management of neuropathic pain (non-malignant pain) as well as pain associated with cancer (malignant pain). According to a manufacturer of an electroceutical nerve block device, the electroceutical treatment approach is based on the non-invasive application of controlled, specific parameter bioelectric impulses.

Electrical current is altered via special step-down transformers into bioelectric impulses, which are designed to mimic the human bioelectric system. Currently, there are 2 distinctive electroceutical classifications:stimulatory class in which repetitive action potentials are induced in excitable cells (depolarization and repolarization activity), andmulti-facilitory class that produces biophysical effects without repetitive action potential propagation. The proper electroceutical class, dosage, regimen duration and anatomical placement of electrodes are determined by the individual patient's diagnosis.

Proponents of electroceutical therapy claim that its use has resulted in significant relief of pain and elimination or drastic reductions in patients' pain medication requirements, such that patients are able to resume their daily activities. However, there is a lack of scientific evidence to substantiate these claims. Guidelines from the Work Loss Data Institute (2008) considered, but did not recommend, electroceutical therapy for chronic pain.

Well-designed, randomized controlled clinical studies are needed to determine the usefulness of electroceutical therapy in the treatment of patients with acute or chronic pain. Transcutaneous Electrical Joint Stimulation and Pulsed Electrical Stimulation: Transcutaneous electrical joint stimulation is also known as pulsed electrical stimulation; and the Bionicare device uses this type of electrical stimulation.

Zizic et al (1995) evaluated the safety and effectiveness of pulsed electrical stimulation for the treatment of osteoarthritis (OA) of the knee (n = 78). Patients were treated 6 hours/day for 4 weeks. The investigators reported that patients treated with the active devices showed significantly greater improvement than the placebo group for all primary efficacy variables in comparisons of mean change from baseline to the end of treatment.

Improvement of greater or equal to 50 % from baseline was shown in at least 1 primary efficacy variable in 50 % of the active device group, in 2 variables in 32 %, and in all 3 variables in 24 %. In the placebo group improvement of greater or equal to 50 % occurred in 36 % for one, 6 % for 2, and 6 % for 3 variables.

Mean morning stiffness decreased 20 mins in the active device group and increased 2 mins in the placebo group (p < 0.05).

No statistically significant differences were observed for tenderness, swelling, or walking time. The authors concluded that improvements in clinical measures for pain and function found in this study suggest that pulsed electrical stimulation is effective for treating OA of the knee.

The investigators noted, however, that studies of the durability of results are warranted. In a Cochrane review on pulsed electric stimulation for the treatment of OA (Hulme et al, 2002), the authors stated that current evidence suggests that electrical stimulation therapy may provide significant improvements for knee OA, but further studies are required to confirm whether the statistically significant results shown in these trials confer clinically significant and durable benefits.

A systematic evidence review by Mc Carthy et al (2006) concluded that pulsed electromagnetic field therapy is unlikely to benefit patients with knee osteoarthritis. The systematic evidence review identified 5 RCTs of pulsed electromagnetic field therapy for knee osteoarthritis: 2 RCTs scored 5 points for validity, 1 scored 4 and 2 scored 3.

The investigators found that none of the individual studies reported a statistically significant difference between treatments for pain. Only 1 study (n = 83) with a low quality score of 3 reported a statistically significant difference between treatments in function (standardized mean difference -0.58, 95 % CI: -1.02 to -0.14). For all studies combined, there was no significant difference between interventions in pain (weighted mean difference -0.66, 95 % CI: -1.67 to 0.35) or function (weighted mean difference -0.70, 95 % CI: -1.92 to 0.52).

Fary and colleagues (2008) stated that OA of the knee is one of the main causes of musculoskeletal disability in the western world. Current available management options provide symptomatic relief (exercise and self-management, medication and surgery) but do not, in general, address the disease process itself.

Moreover, adverse effects and complications with some of these interventions (medication and surgery) and the presence of co-morbidities commonly restrict their use.

There is clearly a need to investigate treatments that are more widely applicable for symptom management and which may also directly address the disease process itself. The authors described the protocol of a double-blind, randomized, placebo-controlled, repeated measures trial to examine the effectiveness of pulsed electrical stimulation in providing symptomatic relief for people with OA of the knee over 26 weeks.

A total of 70 subjects will be recruited and information regarding age, gender, body mass index and medication use will be recorded.

The population will be stratified for age, gender and baseline pain levels. Outcome measures will include pain (100 mm VAS and Western Ontario and Mc Master Universities Osteoarthritis Index [WOMAC] 3.1), function (WOMAC 3.1), stiffness (WOMAC 3.1), patient global assessment (100 mm VAS) and quality of life (Medical Outcomes Study Short-Form 36 [SF-36]). These outcomes will be measured at baseline, 4, 16 and 26 weeks. Activity levels will be measured at baseline and 16 weeks using accelerometers and the Human Activity Profile questionnaire.

A patient global perceived effect scale (11-point Likert) will be completed at 16 and 26 weeks. In a double-blind, randomized, placebo-controlled, repeated-measures study, Fary et al (2011) determined the effectiveness of subsensory, pulsed electrical stimulation (PES) in the symptomatic management of OA of the knee.

A total of 70 participants with clinical and radiographically diagnosed OA of the knee were randomized to either PES or placebo. The primary outcome was change in pain score over 26 weeks measured on a 100-mm VAS. Other measures included pain on the WOMAC, function on the WOMAC, patient's global assessment of disease activity (on a 100-mm VAS), joint stiffness on the WOMAC, quality of life on the SF-36 health survey, physical activity (using the Human Activity Profile and an accelerometer), and global perceived effect (on an 11-point scale).

Thirty-four participants were randomized to PES and 36 to placebo. Intent-to-treat analysis showed a statistically significant improvement in VAS pain score over 26 weeks in both groups, but no difference between groups (mean change difference 0.9 mm [95 % CI: -11.7 to 13.4]).

Similarly, there were no differences between groups for changes in WOMAC pain, function, and stiffness scores (-5.6 [95 % CI: -14.9 to 3.6], -1.9 [95 % CI: -9.7 to 5.9], and 3.7 [95 % CI: -6.0 to 13.5], respectively), SF-36 physical and mental component summary scores (1.7 [95 % CI: -1.5 to 4.8] and 1.2 [95 % CI: -2.9 to 5.4], respectively), patient's global assessment of disease activity (-2.8 [95 % CI: -13.9 to 8.4]), or activity measures; 56 % of the PES-treated group achieved a clinically relevant 20-mm improvement in VAS pain score at 26 weeks compared with 44 % of controls (12 % [95 % CI: -11 % to 33 %]).

The authors concluded that in this sample of subjects with mild-to-moderate symptoms and moderate-to-severe radiographic OA of the knee, 26 weeks of PES was no more effective than placebo.

Mendel et al (2010) noted that high-voltage pulsed current (HVPC), a form of electrical stimulation, is known to curb edema formation in laboratory animals and is commonly applied for ankle sprains, but the clinical effects remain undocumented. In a multi-center, randomized, double-blind, placebo-controlled trial, these investigators examined if, as an adjunct to routine acute and subacute care, subsensory HVPC applied nearly continuously for the first 72 hours after lateral ankle sprains affected time lost to injury.

Data were collected at 9 colleges and universities and 1 professional training site. A total of 50 intercollegiate and professional athletes were included in this study. Participants were given near-continuous live or placebo HVPC for 72 hours post-injury in addition to routine acute and subacute care.

Main outcome measure was time lost to injury measured from time of injury until declared fit to play. Overall, time lost to injury was not different between treated and control groups (p = 0.55). However, grade of injury was a significant factor. Time lost to injury after grade I lateral ankle sprains was greater for athletes receiving live HVPC than for those receiving placebo HVPC (p = 0.049), but no differences were found between groups for grade II sprains (p = 0.079).

The authors concluded that application of subsensory HVPC had no clinically meaningful effect on return to play after lateral ankle sprain. Electro-Acuscope Myopulse: The Electro-Acuscope Myopulse Therapy System is an electronic device that has been used for a wide range of neuromuscular conditions.

The Acuscope uses electricity to treat pain by stimulating the nervous system without puncturing the skin. The Myopulse, a companion instrument to the Acuscope, stimulates muscles, tendons and ligaments, reducing spasm, inflammation and strengthening tissue damaged by traumatic injury. This form of therapy purportedly helps the body heal itself by stimulating the supply of blood and oxygen to the involved area. The Electro-Acuscope Myopulse Therapy System has been used in the treatment of pain and many types of tissue damage including swelling, inflammation, and soreness. However there is insufficient scientific evidence to support its effectiveness. Sacral Nerve Root and Lumbosacral Plexus Stimulation: Electrical stimulation of the sacral nerves (sacral neuromodulation) or lumbosacral plexus has been used for painful conditions resulting from chronic abdominal, pelvic, genital, and anal pain syndromes (Kim, 2004).

Specific conditions that have been treated include pain from interstitial cystitis, coccydynia, pyelonephritis, pancreatitis, rectal fugax, and vulvodynia. Procedures allowing access to sacral and lumbosacral nerves include a retrograde (cephalocaudad) epidural approach and a sacral transforaminal approach.

The transforaminal approach is mainly used for the treatment of urge urinary incontinence and urinary retention, while the retrograde approach has been used primarily for the treatment of pelvic pain. Evidence for sacral nerve root and lumbosacral plexus stimulation is limited to case reports and small case series.

Alo and colleagues (1999) reported that lumbar and sacral nerve root stimulation through the retrograde approach resulted in adequate paresthesia and effective pain relief as reflected by VAS scores in 5 patients with chronic pain (e.g., ilioinguinal neuralgia, discogenic LBP, failed back syndrome, and vulvodynia). These investigators concluded that further clinical trials are needed to assess the safety and long-term success rates of lumbar/sacral nerve root stimulation in the management of patients with chronic pain. Anterograde sacral nerve root stimulation (SNRS) through the sacral hiatus is another method that has been tried for the treatment of pelvic pain.

In a case report study, Falco et al (2003) found that anterograde SNRS provided good pain relief (as indexed by VAS scores) in a patient with chronic pelvic (rectal, coccygeal, and perineal) pain. The authors concluded that further investigation is needed before any conclusions can be rendered regarding the reliability of SNRS in the treatment of theses disorders.

Siegel and colleagues (2001) examined the effectiveness of transforaminal sacral nerve stimulation in patients with chronic intractable pelvic pain. After successful percutaneous trial stimulation, a neuroprosthetic sacral nerve stimulation device was surgically implanted in 10 patients with chronic intractable pelvic pain. Leads were placed in the S3 and S4 foramen in 8 and 2 cases, respectively. Patients were evaluated throughout the study using a patient pain assessment questionnaire on a scale of 0 (absence of pain) to 5 (excruciating pain).

Pain was assessed at baseline, during test stimulation, and 1, 3 and 6 months after implantation of surgical lead. An additional long-term assessment was done at a median follow-up of 19 months. Of the 10 patients with the implant, 9 had a decrease in the severity of the worst pain compared to baseline at a median follow-up of 19 months.

The number of hours of pain decreased from 13.1 to 6.9 at the same follow-up interval. There was also an average decrease in the rate of pain from 9.7 at baseline to 4.4 on a scale of 10 (always having pain) to 0 (never having pain).

At a median of 19 months, 6 of 10 patients reported significant improvement in pelvic pain symptomatology. The authors concluded that these data imply that transforaminal sacral nerve stimulation can have beneficial effects on the severity and frequency of chronic intractable pelvic pain. They further stated that future clinical studies are necessary to determine the long-term effectiveness of this therapy. The available evidence on sacral nerve root and lumbosacral plexus stimulation is insufficient to draw reliable conclusions about the effect of these interventions on chronic pelvic and abdominal pain.

Microcurrent Therapy: Microcurrent electrical nerve stimulation (MENS) devices are also non-invasive devices in which precise, tightly controlled electrical current is applied to specific points on the body. These specific points correspond with classical acupuncture points. MENS is also referred to as microelectrical therapy (MET) or microelectrical neuro-stimulation.

Examples of this type of device include, but may not be limited to, Algonix, Alpha-Stim 100, Electro-Lyoscope 85P, Electro-Myopulse 75L, KFH Energy, MENS 2000-D, MICROCURRENT and Myopulse 75C.

Microcurrent therapy (MCT), also known as low-voltage microampere stimulation, is characterized by sub-sensory current that acts on the body’s naturally occurring electrical impulses to decrease pain and facilitate the healing process. It uses microamperage instead of milliamperage to drive its current into the injured site. Microcurrent therapy uses current between 1 and 1,000 micro A at a voltage of 10 to 60 V, and a frequency of 0.5 to 100 Hz. It differs from TENS in that it uses a significantly reduced electrical stimulation. While TENS blocks pain, MCT acts on the naturally occurring electrical impulses to decrease pain by stimulating the healing process.

Koopman et al (2009) stated that MCT is a novel treatment for pain syndromes. The MCT patch is hypothesized to produce stimuli that promote tissue healing by facilitating physiologic currents.

Solid evidence from randomized clinical trials is lacking. To assess the effectiveness of MCT in treating non-specific, chronic LBP, these researchers conducted a double-blind, randomized, cross-over, pilot trial. A total of 10 succeeding patients presenting with non-specific, chronic LBP were included. Patients started with 2, 9-day baseline period followed by a 5-day treatment periods. During the treatment periods, either a placebo or MCT (verum) patch was randomly assigned. Mean and worst pain scores were evaluated daily by a VAS.

Furthermore, analgesic use, side effects, and quality of life were assessed after each period. Differences between the last 4 days of a treatment period and the baseline period were calculated. Differences between verum and placebo periods per patient were compared using paired-t tests. A 20-mm VAS score reduction was considered clinically relevant.

The VAS score was lower during verum treatment, with a reduction (95 % CI) of -0.43 (-1.74; 0.89) in mean and -1.07 (-2.85; 0.71) in worst pain. Analgesic use decreased during verum treatment, except for non-steroid anti-inflammatory drug use, which increased. Quality of life improved during verum treatment. However, none of the findings was statistically significant.

A positive trend in MCT use for aspecific, chronic LBP was reported. The authors stated that further investigations are needed to evaluate the significance and relevance of these findings.

Furthermore, the American Pain Society's clinical practice guideline on non-surgical interventional therapies for LBP (Chou et al, 2009) concluded that few non-surgical interventional therapies for LBP have been shown to be effective in randomized, placebo-controlled trials.

Zuim et al (2006) evaluated the effect of microcurrent electrical nerve stimulation (MENS) and compared with occlusal splint therapy in temporo-mandibular disorders (TMD) patients with muscle pain. A total of 20 TMD patients were divided into 4 groups. One received occlusal splint therapy and MENS (I); other received splints and placebo MENS (II); the third, only MENS (III) and the last group, placebo MENS (IV). Sensitivity derived from muscle palpation was evaluated using a VAS. Results were submitted to analysis of variance (p < 0.05).

There was reduction of pain level in all groups: group I (occlusal splint and MENS) had a 47.7 % reduction rate; group II (occlusal splint and placebo MENS), 66.7 %; group III (MENS), 49.7 % and group IV (placebo MENS), 16.5 %.

In spite of that, there was no statistical difference (analysis of variance/p < 0.05) between MENS and occlusal splint therapy regarding muscle pain reduction in TMD patients after 4 weeks.

In a placebo-controlled, single-blinded, and randomized study, Gossrau et al (2011) evaluated the effect of micro-TENS in reducing neuropathic pain in patients with painful diabetic neuropathy (PDN). A total of 22 diabetic patients have been treated with a micro-TENS therapy and 19 patients have been treated with a placebo therapy.

Treatment duration was 4 weeks with 3 therapeutic settings per week. Standardized questionnaires (Pain Disability Index [PDI], neuropathic pain score [NPS], Center for Epidemiologic Studies Depression Scale [CES-D]) were used to assess pain intensity, pain disability, as well as quality of life at baseline at the end of the treatment period and 4 weeks after treatment termination.

Patients with a minimum of 30 % reduction in NPS were defined as therapy responders. After 4 weeks of treatment, 6/21 (28.6 %) patients in the verum group versus 10/19 (52.6 %) patients in the placebo group responded to therapy. The median PDI score after 4 weeks of treatment showed a reduction of 23 % in the verum versus 25 % in the placebo group.

The differences did not reach statistical significance. The authors concluded that the pain reduction with the applied transcutaneous electrotherapy regimen is not superior to a placebo treatment.

Scrambler Therapy/The Calmare Therapy Device: Scrambler therapy (also known as transcutaneous electrical modulation pain reprocessing) is an electro-cutaneous nerve stimulation device that interferes with pain signal transmission by mixing a ''non-pain'' information into the nerve fibers. It consists of a multi-processor apparatus capable of simulating 5 artificial neurons that send out signals identified by the central nervous system as ""no pain"" via the application of surface electrodes on skin in the pain areas.

Marineo (2003) examined the effects of the Scrambler therapy in the treatment of drug-resistant oncological pain of the visceral/neuropathic type. A total of 11 terminal cancer patients (3 pancreas, 4 colon, 4 gastric) suffering from elevated drug resistant visceral pain were included in this study. The trial program was related to the first 10 treatment sessions. Subsequently, each patient continued to receive treatment until death.

Pain measures were performed using the VAS before and after each treatment session and accompanied by diary recordings of the duration of analgesia in the hours following each single application. Any variation in pain-killing drug consumption was also recorded. All patients reacted positively to the treatment throughout the whole reference period.

Pain intensity showed a significant decrease (p < 0.001), accompanied by a gradual rise both in the pain threshold and the duration of analgesia; 9 (81.8 %) of the patients suspended pain-killers within the first 5 applications, while the remaining 2 (18.2 %) considerably reduced the dosage taken prior to Scrambler therapy.

No undesirable side effects were observed. Compliance was found to be optimal. The authors concluded that these preliminary results obtained using Scrambler therapy were extremely encouraging, both in terms of enhanced pain control after each treatment session and in view of the possible maintenance of effectiveness over time. Sabato et al (2005) assessed the effectiveness of the Scrambler therapy in the treatment of neuropathic pain. A total of 226 patients, all suffering from intense drug-resistant neuropathic pain, were recruited for this trial. Inclusion criteria included neuropathic pain, very high baseline VAS. Exclusion criteria included pacemaker users, neurolithic blocks or neurolesive pain control treatment.

The treated neuropathic pain syndromes were: failed back surgery syndrome (FBSS), post-herpetic neuralgia (PHN), trigeminal neuralgia, post-surgery nerve lesion neuropathy, pudendal neuropathy, brachial plexus neuropathy, LBP, and others.

The trial program entailed 1 to 6 therapy sessions of 5 treatments, each one lasting 30 mins. Pain intensity was evaluated using VAS before and after each treatment. The statistical significance of VAS was measured using the paired t-test. The total results showed 80.09 % of responders (pain relief greater than 50 %), 10.18 % of partially responders (pain relief from 25 % to 49 %) and 9.73 % of no responders (patients with pain relief less than 24 % or VAS greater than 3).

The authors concluded that the Scrambler therapy produced a statistically significant (p < 0.0001) pain relief in all treated neuropathies. In a pilot study, Marineo et al (2012) compared guideline-based drug management with Scrambler therapy.

A clinical trial with patients randomized to either guideline-based pharmacological treatment or Scrambler therapy for a cycle of 10 daily sessions was performed. Patients were matched by type of pain including post-surgical neuropathic pain, PHN, or spinal canal stenosis.

Primary outcome was change in VAS pain scores at 1 month; secondary outcomes included VAS pain scores at 2 and 3 months, pain medication use, and allodynia. A total of 52 patients were randomized. The mean VAS pain score before treatment was 8.1 points (control) and 8.0 points (Scrambler). At 1 month, the mean VAS score was reduced from 8.1 to 5.8 (-28 %) in the control group, and from 8 to 0.7 points (-91 %) in the Scrambler group (p < 0.0001).

At 2 and 3 months, the mean pain scores in the control group were 5.7 and 5.9 points, respectively, and 1.4 and 2 points in the Scrambler group, respectively (p < 0.0001).

More relapses were seen in polyradicular pain than monoradicular pain, but re-treatment and maintenance therapy gave relief. No adverse effects were observed. The authors concluded that in this pilot randomized trial, Scrambler therapy appeared to relieve chronic neuropathic pain better than guideline-based drug management.

In a pilot study, Smith et al (2010) evaluated the impact on chemotherapy-induced peripheral neuropathy (CIPN) associated with the MC5-A Calmare therapy device. A total of 18 patients from 1 center received 1-hour interventions daily over 10 working days. Of 18 patients, 16 were evaluable. The mean age of the patients (4 men and 14 women) was 58.6 years and the duration of CIPN was 3 months to 8 years.

The most common drugs used by these subjects were taxanes, platinum, and bortezomib. At the end of the study (day 10), a 20 % reduction in numeric pain scores was achieved in 15 of 16 patients.

The pain score fell 59 % from 5.81 +/- 1.11 before treatment to 2.38 +/- 1.82 at the end of 10 days (p < 0.0001 by paired t-test). A daily treatment benefit was seen with a strong statistically significant difference between the pre- and post-daily pain scores (p < 0.001). Four patients had their CIPN reduced to zero. A repeated-measures analysis using the scores from all 10 days confirmed these results.

No toxicity was seen. Some responses have been durable without maintenance. The authors concluded that patient-specific cutaneous electro-stimulation with the MC5-A Calmare device appears to dramatically reduce pain in refractory CIPN patients with no toxicity.

They stated that further studies (determining effectiveness compared with sham or placebo treatment, and the need for maintenance therapy) are underway to define the benefit, mechanisms of action, and optimal schedule.

The preliminary findings of this pilot study need to be validated by well-designed studies. There is a phase II clinical trial that examines the effectiveness of the MC5-A Scrambler therapy in reducing peripheral neuropathy caused by chemotherapy. Ricci et al (2012) evaluated the effectiveness of an innovative neuromodulative approach to the treatment of chronic pain using electrical stimulus integrated with pharmacological support. The MC5-A Calmare is a new device for patient-specific cutaneous electro-stimulation which, by ""scrambling"" pain information with ""no pain"" information, aims to reduce the perception of pain intensity.

These researchers prospectively treated 73 patients with cancer-related (n = 40) and non-cancer-related (n = 33) pain whose pain management was unsatisfactory. The primary objective of the study was to assess efficacy and tolerability of the device. Pain intensity was assessed daily with a Numerical Rating Scale (NRS) for the duration of treatment (2 weeks) and then on a weekly basis for the 2 weeks of follow-up.

Mean pain value at T0 (pre-treatment value) was 6.2 [+/- 2.5 SD], 1.6 (+/- 2.0) (p < 0.0001) at T2 (after the 10th day of treatment), and 2.9 (+/- 2.6) (p < 0.0001) at T4 (after the second week of follow-up, i.e., 1 month after the beginning of treatment).

Response after the second week of treatment showed a clear reduction in pain for both cancer (mean absolute delta of the reduction in NRS value = 4.0) and non-cancer (mean delta = 5.2) patients.

The pain score had decreased by 74 % at T2. On the basis of pre-established response criteria, there were 78 % of responders at T2 and 81 % at T4. No side effects were reported. The authors concluded that these preliminary results suggested that cutaneous electro-stimulation with the MC5-A Calmare can be hypothesized as part of a multi-modality approach to the treatment of chronic pain.

They stated that further studies on larger numbers of patients are needed to assess its efficacy, to quantify the effects of inter-operator variability, and to compare results obtained from the active device versus those from a sham machine.

Smith and Marineo (2013) noted that post-herpetic neuropathy (PHN) is common, severe, and often refractory to treatment. These investigators treated 10 patients with refractory PHN using Scrambler therapy, a neurocutaneous stimulation device that delivers ""non-pain"" information with surface electrodes.

Scrambler therapy was given as 30-minute sessions daily for 10 days. Pain was recorded before and after treatment. The average pain score rapidly diminished from 7.64 ± 1.46 at baseline to 0.42 ± 0.89 at 1 month, a 95 % reduction, with continued relief at 2 and 3 months. Patients achieved maximum pain relief with less than 5 treatments. The authors concluded that the Scrambler therapy appeared to have a promising effect on PHN, with prompt and continued relief and no side effects.

They stated that further research is warranted. Pachman et al (2014) stated that chemotherapy-induced peripheral neuropathy (CIPN) is a common toxicity associated with multiple chemotherapeutic agents. CIPN may have a detrimental impact on patients' quality of life and functional ability, as well as result in chemotherapy dose reductions.

Although symptoms of CIPN can improve with treatment completion, symptoms may persist. Currently, the treatment options for CIPN are quite limited. Duloxetine, a serotonin-norepinephrine reuptake inhibitor, has the most evidence supporting its use in the treatment of CIPN. Other agents with potential benefit for the treatment of established CIPN include gabapentinoids, venlafaxine, tricyclic antidepressants, and a topical gel consisting of the combination of amitriptyline, ketamine, and baclofen; none of these, however, has been proven to be helpful and ongoing/future studies may well show that they are not beneficial.

The use of these agents is often based on their efficacy in the treatment of non-CIPN neuropathic pain, but this does not necessarily mean that they will be helpful for CIPN-related symptoms.

Other non-pharmacologic interventions including acupuncture and Scrambler therapy are supported by positive preliminary data; however, further larger, placebo-controlled trial data are needed to confirm or refute their effectiveness.

In a double-blinded, randomized controlled trial, Starkweather et al (2015) evaluated the effects of Calmare, a non-invasive neurocutaneous electrical pain intervention, on lower back pain intensity as measured by the ""worst"" pain score and on pain interference using the Brief Pain Inventory-Short Form, on measures of pain sensitivity assessed by quantitative sensory testing, and on m RNA expression of pain sensitivity genes.

A total of 30 participants were randomized to receive up to 10 sessions of Calmare® treatment (n = 15) or a sham treatment (n = 15) using the same device at a non-therapeutic threshold.

At 3 weeks after conclusion of treatment, compared with the sham group, the Calmare® group reported a significant decrease in the ""worst"" pain and interference scores.

There were also significant differences in pain sensitivity and differential m RNA expression of 17 pain genes, suggesting that Calmare® can be effective in reducing pain intensity and interference in individuals with persistent low back pain by altering the mechanisms of enhanced pain sensitivity. The authors stated that further study of long-term pain outcomes, particularly functional status, analgesic use and health care utilization, is warranted.

Pachman et al (2015) stated that CIPN, a common side effect of chemotherapy, needs better effective treatments. Preliminary data support the use of Scrambler therapy, a device which treats pain via noninvasive cutaneous electrostimulation, for the treatment of CIPN.

The current manuscript reported data from a pilot trial, performed to investigate the effect of Scrambler therapy for the treatment of established CIPN. Eligible patients had CIPN symptoms of greater than or equal to 1 month duration with tingling and/or pain greater than or equal to 4/10 during the prior week.

Patients were treated with Scrambler therapy to the affected area (s) for up to 10 daily 30-min sessions. Symptoms were monitored using a neuropathy questionnaire consisting of numerical analog scales ranging from 0 to 10, daily before therapy as well as weekly for 10 weeks after therapy.

Descriptive summary statistics formed the basis of data analysis. A total of 37 patients were enrolled; 25 patients were treated primarily on their lower extremities while 12 were treated primarily on their upper extremities.

There was a 53 % reduction in pain score from baseline to day 10; a 44 % reduction in tingling; and a 37 % reduction in numbness. Benefit appeared to last throughout 10 weeks of follow-up. There were no substantial adverse events.

The authors concluded that preliminary data support that Scrambler therapy may be effective for the treatment of CIPN; they stated that a prospective placebo-controlled clinical trial should be performed. In a single-center, case-series study, Notaro et al (2016) examined the effectiveness of Scrambler therapy in reducing cancer pain induced by skeletal and visceral metastases after failure of standard treatments, including pharmacological therapies and radiation therapy.

A total of 25 consecutive patients underwent Scrambler therapy individually delivered by MC5-A Calmare for 10 daily sessions each of 30 to 40 mins. Pain was measured by a numeric rating scale at baseline, as well as before and after each treatment session; 100 % of patients reached a pain relief of greater than or equal to 50 %.

Pain score was reduced from 8.4 at baseline to 2.9 after treatment, with a mean pain relief of 89 %. The sleeping hours improved from 4.4 ± 1.2 to 7.5 ± 1.1. The duration of pain control by Scrambler therapy was 7.7 ± 5.3 weeks.

No adverse events were observed. The authors concluded that Scrambler therapy did not present toxicity and allowed opioids dosage reduction, and it is also a repeatable treatment. They stated that present novel data support that Scrambler therapy appeared to be effective for the treatment of cancer pain; further evaluation in RCTs is needed to confirm these findings.

Majithia et al (2016) evaluated what is known regarding the mechanisms and mechanics of Scrambler therapy and investigated the preliminary data pertaining to the effectiveness of this treatment modality. The Pub Med/Medline, SCOPUS, Embase, and Google Scholar databases were searched for all articles published on Scrambler therapy prior to November 2015.

All case studies and clinical trials were evaluated and reported in a descriptive manner. To-date, 20 reports, of varying scientific quality, have been published regarding this device; all but 1 small study, published only as an abstract, provided results that appeared positive.

The authors concluded that the positive findings from preliminary studies with Scrambler therapy support that this device provides benefit for patients with refractory pain syndromes. Moreover, they stated that larger, randomized studies are needed to further evaluate the effectiveness of this approach.

Smith and colleagues (2017) stated that chronic post-mastectomy pain (c PMP), including post-lumpectomy pain, is common with no established ways of treatment. These researchers treated 3 consecutive patients referred with c PMP with Scrambler therapy. Treatment was given across the area of pain following the dermatomes for 45 minutes daily, for several consecutive days until relief, and then was repeated as needed.

The Scrambler therapy MC5A device synthesized 16 different waveforms that resemble action potentials, delivered to the surface receptors of the c-fibers, to send ""non-pain"" information along the damaged pathways to reduce central sensitization.

All 3 had marked (over 75 %) and sustained (months) reduction of allodynia, hyperalgesia, and pain. All reported marked improvements in their quality of life and normal function. One woman was able to stop chronic opioid use.

No side effects were observed. The authors concluded that Scrambler therapy is a promising way to relieve cancer and other types of neuropathic pain, and may be helpful in c PMP.

They stated that further prospective clinical trials are needed. Non-Invasive Interactive Neurostimulation (e.g., the Inter X 1000 Neurostimulator Device): The Inter X 1000 neurostimulator appears to be a hand-held, personal device for home use. It delivers interactive, high amplitude, high density stimulation to the cutaneous nerves, activating the body's natural pain relieving mechanisms (segmental and descending inhibition). However, there is insufficient evidence regarding its effectiveness for the treatment of chronic pain.

In a randomized, sham-controlled, pilot study, Selfe et al (2008) examined the effects of non-invasive interactive neurostimulation used as an adjunct to usual care, on pain and other symptoms in adults with OA of the knee.

A total of 37 adults with knee OA (based on American College of Rheumatology diagnostic criteria) were included in this study. Subjects received 17 non-invasive interactive neurostimulation (active or sham) sessions over 8 weeks with a week 12 follow-up.

Outcome measures included 11-point numeric rating scale for weekly pain; WOMAC, patient global assessment, and SF-36 completed at baseline and weeks 4, 8, and 12. For the main outcome, pain, the differences between the groups over time did not reach statistical significance (all p > 0.05).

However, a clinically important reduction in pain (defined as a 2-point or 30 % reduction on an 11-point numeric rating scale) was maintained at week 12 by the active non-invasive interactive neurostimulation group (2.17 points, 34.55 % reduction) but not the sham group (1.63, 26.04 % reduction).

Pain improved over time in participants regardless of group membership (numeric rating scale average pain, p = 0.002; numeric rating scale worst pain, p < 0.001; and WOMAC pain, p < 0.001), as did WOMAC function, WOMAC stiffness, and WOMAC total score (all p < 0.001).

Repeated measures ANOVA revealed a statistically significant difference between the groups over time for the SF-36 Vitality scale, F (3, 105) = 3.54, p = 0.017. In addition, the active device group improved on the patient global assessment from baseline to week 8 compared to the sham device group, F (1, 35) = 4.025, p = 0.053.

The authors concluded that in this pilot study, clinically important reductions in knee pain were maintained at week 12 in the active, but not the sham, non-invasive interactive neurostimulation group. They stated that further study of this non-invasive therapy is needed. Gorodetskyi et al (2010) undertook a trial with 60 patients who had undergone operative reduction and internal fixation of bimalleolar, AO type B2 ankle fractures with comminution.

Patients were randomized into 2 groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device (Inter X) and the other with a sham device. The trial was designed to test the hypothesis that incorporation of non-invasive interactive neurostimulation into the rehabilitation protocol would result in reduced pain, increased range of motion (ROM), reduced edema, and reduced consumption of pain medication, in comparison with the sham therapy group.

Outcome measurements included the patient's subjective assessment of level of pain, ROM, and the extent of edema in the involved ankle, and the use of ketorolac for post-operative control of pain. The authors concluded that these results showed significantly better results in the patients receiving treatment with active neurostimulation (repeated measures analysis of variance, p < 0.001).

In a Cochrane review, Lin and colleagues (2012) evaluated the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults. The authors concluded that there is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilization to allow exercise during the immobilization period after surgical fixation.

Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilization to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilization period after conservative orthopedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilization period. Furthermore, they stated that small, single studies showed that some electrotherapy modalities may be beneficial. They stated that more clinical trials that are well-designed and adequately-powered are needed to strengthen current evidence.

Teodorczyk-Injeyan et al (2015) evaluated the effect of treatment with a novel non-invasive interactive neurostimulation device (Inter X5000) on the production of inflammatory biomarkers in chronic and recurrent mechanical neck pain (NP) syndrome. This study represented pilot biological data from a RCT. A total of 25 NP patients and 14 asymptomatic subjects included for baseline comparison only completed the study. The patients received 6 Inter X5000 or placebo treatments within 2 weeks, and pre-treatment and post-treatment blood samples were collected for in-vitro determination of biomarker production.

Whole blood cell cultures were activated by lipopolysaccharide or by the combination of lipopolysaccharide and phytohemagglutinin for 24 to 48 hours.

The levels of tumor necrosis factor-alpha (TNFα) and its soluble type II receptor (s TNFR II), interleukin (IL) 1, IL-1 receptor antagonist (IL-1RA), IL-6, IL-10, and monocyte chemotactic protein (CCL2/MCP-1) were determined by specific immunoassays. Compared with asymptomatic subjects, baseline production levels of all pro-inflammatory mediators (TNFα, IL-1β, IL-6, and CCL2/MCP-1) were significantly augmented or trended higher (p = 0.000 to 0.008) in patients with NP.

Of the anti-inflammatory markers, only IL-1RA was significantly elevated (p = 0.004). The increase in IL-10 and TNF receptor II levels did not reach statistical significance. Neither Inter X5000 nor placebo therapy had any significant effect on the production of the inflammatory mediators over the study period. The authors concluded that this investigation determined that inflammatory cytokine pathways are activated in NP patients but found no evidence that a short course of Inter X5000 treatment normalized the production of inflammatory biomarkers.

Electro Therapeutic Point Stimulation: Electro-therapeutic point stimulation (ETPS), also known as microcurrent point stimulation (MPS), employs a non-invasive device to administer low-frequency direct current to acupuncture points, motor/trigger points, and contracted muscle bands.

The device (known as called the ETPS 1000) has an enhanced point finder that detects treatment points on the skin and applies brief, concentrated electrical microstimulation in short bursts. This modality/approach combines the principles of acupuncture, massage, physical therapy and microcurrent stimulation. The treatment can be self-administered by the patient at home. There is insufficient peer-reviewed evidence to support the safety and effectiveness of ETPS/MPS. Aliyev and Geiger (2012) examined the effects of cell-stimulation therapy of lateral epicondylitis with frequency-modulated low-intensity electric current.

Patients with lateral epicondylitis were subjected to a 12-week cell-stimulation therapy with low-intensity frequency-modulated electric current in addition to routine therapy. Patients in the control group received the same routine therapy and sham stimulation (the therapeutic apparatus was not energized).

The effectiveness of MPS was estimated by comparing medical indices before therapy and at the end of a 12-week therapeutic course using a 10-point pain severity numeric rating scale (NRS) and Roles-Maudsley pain score. The study revealed high therapeutic efficiency of cell-stimulation with low-intensity electric current resulting probably from up-regulation of intracellular transmitters, interleukins, and prostaglandins playing the key role in the regulation of inflammation.

The findings of this study need to be validated by well-designed studies with long-term follow-up. Pulsed Stimulation (e.g., P-Stim): In a pilot study, Sator-Katzenschlager et al (2003) tested the hypothesis that auricular electro-acupuncture (EA) relieves pain more effectively than conventional manual auricular acupuncture.

These researchers studied 21 chronic cervical pain patients without radicular symptoms with insufficient pain relief (VAS greater than 5) treated with standardized analgesic therapy. All patients received disposable acupuncture needles on the dominant side on the following acupuncture points: cervical spine, shen men, and cushion. In 10 patients, needles were continuously stimulated (2-m A constant current, 1 Hz monophasic) by using the electrical point stimulation device P-STIM.

In 11 control patients, no electrical stimulation was administered. All needles were withdrawn 48 hrs after insertion. Acupuncture was performed once a week for 6 wks. Patients had to complete a questionnaire assessing pain intensity, psychological well-being, activity, sleep, and demand for rescue medication (lornoxicam and tramadol).

The reduction in pain scores was significant in the EA group. Similarly, psychological well-being, activity, and sleep were significantly improved in patients receiving EA, and consumption of rescue medication was significantly less. These results demonstrated that continuous electrical stimulation of auricular acupuncture points by using the new point stimulation device P-STIM improves the treatment of chronic cervical pain in an outpatient population. The authors concluded that continuous electrical stimulation of auricular acupuncture points by using the new point stimulation device P-STIM significantly decreases pain intensity and significantly improves psychological well-being, activity, and sleep in chronic cervical pain patients.

This was a pilot study with small number of subjects with short-term follow-up. In a prospective, randomized, double-blind, controlled study, Sator-Katzenschlager et al (2004) tested the hypothesis that auricular EA relieves pain more effectively than conventional manual auricular acupuncture (CO) in chronic LBP patients with insufficient pain relief (VAS greater than or equal to 5) treated with standardized analgesic therapy.

Disposable acupuncture needles were inserted in the auricular acupuncture points 29, 40, and 55 of the dominant side and connected to a newly developed battery-powered miniaturized stimulator worn behind the ear.

Patients were randomized into group EA (n = 31) with continuous low-frequency auricular EA (1 Hz biphasic constant current of 2 m A) and group CO (n = 30) without electrical stimulation (sham-EA). Treatment was performed once-weekly for 6 wks, and in each group needles were withdrawn 48 hrs after insertion. During the study period and a 3-month follow-up, patients were asked to complete the Mc Gill questionnaire.

Psychological well-being, activity level, quality of sleep, and pain intensity were assessed by means of VAS; moreover, analgesic drug consumption was documented. Pain relief was significantly better in group EA during the study and the follow-up period as compared with group CO. Similarly, psychological well-being, activity, and sleep were significantly improved in group EA versus group CO, the consumption of analgesic rescue medication was less, and more patients returned to full-time employment.

Neuropathic pain in particular improved in patients treated with EA. There were no adverse side effects. These results were the first to demonstrate that continuous EA stimulation of auricular acupuncture points improves the treatment of chronic LBP in an out-patient population.

The authors concluded that continuous electrical stimulation of auricular acupuncture points using the new point stimulation device P-Stim significantly decreases pain intensity and improves psychological well-being, activity, and sleep in chronic LBP patients. This was a small study with a short-term follow-up. Sator-Katzenschlager and Michalek-Sauberer (2007) stated that acupuncture is now accepted as a complementary analgesic treatment.

Auricular acupuncture is a distinct form of acupuncture. Electrical stimulation of acupoints (EA) increases the effects of acupuncture. Recently, an auricular EA device, the P-Stim, has become available. Clinical studies in outpatients have investigated the P-Stim in chronic musculo-skeletal pain and its use for minor surgery.

In chronic cervical or LBP, auricular EA was more effective than conventional auricular acupuncture. The results in acute pain were controversial. Auricular EA reduced pain and remifentanil consumption during oocyte aspiration when compared with conventional auricular acupuncture or a sham treatment. However, after third molar tooth extraction, auricular EA and auricular acupuncture failed to reduce either postoperative pain or analgesic consumption. The authors concluded that further large-scale studies are needed to evaluate the analgesic efficacy of auricular EA.

Michalek-Sauberer et al (2007) examined the effects of auricular EA on pain and analgesic drug consumption in the first 48 hrs after unilateral mandibular third molar tooth extraction under local anesthesia in a prospective, randomized, double-blind, placebo-controlled study in 149 patients.

Patients received either auricular acupuncture with electrical stimulation (AE, n = 76) or without (AA, n = 37) electrical stimulation at an alternating frequency of 2/100 Hz or a sham AE with metal plates instead of needles and no electrical stimulation, no-needle (NN, n = 36) at the AA points 1 (tooth), 55 (Shen men) and 84 (mouth) during the entire study period.

Regularly rated pain intensity (5-point verbal rating scale), consumption of acetaminophen 500-mg tablets and additional rescue medication with 500-mg mefenamic acid were assessed.

The median fraction of time when pain was rated as moderate or worse (upper and lower quartile): AE: 33 % (12 %, 64 %), AA: 22 % (6 %, 56 %), NN: 30 % (7 %, 53 %) did not differ significantly among the treatment groups. There were no significant differences in mean number of acetaminophen 500-mg tablets (range): AE: 5.2 (0 to 12), AA: 4.6 (0 to 11), NN: 5.4 (0 to 10) or percentage of patients requiring additional mefenamic acid: AE: 19 %, AA: 18 %, NN: 19 %.

The authors concluded that neither AE nor AA alone reduce either pain intensity or analgesic consumption in a molar tooth extraction model of acute pain. Wang (2007) reported the successful treatment of a patient with post-herpetic neuralgia (PHN) using traditional pharmacology in combination with acupuncture.

A 13-year old girl developed PHN following a severe attack of varicella zoster. Despite a 1-week course of intravenous acyclovir initiated at the onset of symptoms, the patient developed persistent left facial pain and constant nausea after lesions were healed.

A comprehensive pain treatment regimen, consisting of a stellate ganglia block, medications, transcutaneous electrical nerve stimulation and hypnosis, was administered, but the patient did not gain any incremental pain relief. The acupuncture service was consulted to provide assistance with this patient's pain management. A combination of body and auricular acupuncture as well as related techniques, including acupressure and transcutaneous acupoint electrical stimulation, was added to the pain treatment regimen.

After 10 complementary acupuncture treatments over a 2-month period, the patient's nausea disappeared. Her left facial pain continued to decline from a maximum of 10 to 0 as assessed by a VAS over a period of 4 months following self-administered treatments of acupressure and transcutaneous acupoint electrical stimulation. The patient was then gradually weaned off all her medications and the complementary acupuncture treatment.

She was discharged from the pediatric pain clinic after 5 months of the combined therapy. The author concluded that acupuncture and its related techniques may be an effective adjunctive treatment for symptoms associated with PHN and deserved further study.

Holzer et al (2011) examined the effects of electrical auricular acupuncture (AA) on post-operative pain in patients undergoing laparoscopy with an emphasis on patient-blinding and the exclusion of therapist-patient interactions. With institutional review board approval and written informed consent, these investigators included 40 female patients undergoing laparoscopy.

Patients were randomly assigned to receive AA (shen men, thalamus and 1 segmental organ-specific point) or electrodes only and an electrical stimulation device. All patients received this intervention under general anesthesia guaranteeing patient blinding and excluding therapist-patient interactions.

Needles and devices were removed 72 hours post-operatively. Post-operatively, patients received 1,000-mg paracetamol every 6 hours. Additional piritramide was given on demand. A blinded observer obtained the VAS scores at 0, 2, 24, 48, and 72 hours as well as the post-operatively administered doses of piritramide. There was no difference in VAS scores or the consumption of piritramide during the first 72 hours post-operatively between groups (acupuncture versus placebo: 2.32 [1.40 to 3.25] versus 2.62 [1.89 to 3.36] average pain on VAS 0-10; 15.3 [12.0 to 18.6] mg versus 13.9 [10.5 to 17.3] mg piritramide).

Values are expressed as mean CI. The authors concluded that the findings of this study showed no reduction in post-operative pain or an opioid sparing effect of auricular acupuncture in women undergoing laparoscopic procedures. Because the authors emphasized blinding of the patients and the exclusion of therapist-patient interactions, this study suggested that electrical auricular acupuncture has no effect on post-operative pain.

In a double-blind, randomized, placebo-controlled, repeated-measures trial, Fary and colleagues (2011) examined the effectiveness of sub-sensory, pulsed electrical stimulation (PES) in the symptomatic management of osteoarthritis (OA) of the knee. A total of 70 participants with clinical and radiographically diagnosed OA of the knee were randomized to either PES or placebo.

The primary outcome was change in pain score over 26 weeks measured on a 100-mm VAS. Other measures included pain on the Western Ontario and Mc Master Universities Osteoarthritis Index (WOMAC), function on the WOMAC, patient's global assessment of disease activity (on a 100-mm VAS), joint stiffness on the WOMAC, quality of life on the Medical Outcomes SF-36 health survey, physical activity (using the Human Activity Profile and an accelerometer), and global perceived effect (on an 11-point scale).

Thirty-four participants were randomized to PES and 36 to placebo. Intent-to-treat analysis showed a statistically significant improvement in VAS pain score over 26 weeks in both groups, but no difference between groups (mean change difference 0.9 mm [95 % CI: -11.7 to 13.4]).

Similarly, there were no differences between groups for changes in WOMAC pain, function, and stiffness scores (-5.6 [95 % CI: -14.9 to 3.6], -1.9 [95 % CI: -9.7 to 5.9], and 3.7 [95 % CI: -6.0 to 13.5], respectively), SF-36 physical and mental component summary scores (1.7 [95 % CI: -1.5 to 4.8] and 1.2 [95 % CI: -2.9 to 5.4], respectively), patient's global assessment of disease activity (-2.8 [95 % CI: -13.9 to 8.4]), or activity measures; 56 % of the PES-treated group achieved a clinically relevant 20-mm improvement in VAS pain score at 26 weeks compared with 44 % of controls (12 % [95 % CI: -11 5 to 33 %]).

The authors concluded that in this sample of subjects with mild-to-moderate symptoms and moderate-to-severe radiographic OA of the knee, 26 weeks of PES was no more effective than placebo.

Neurolumen Device: The Neurolumen is a portable machine that consists of a control unit, 4 wrap assemblies and a battery charger. Each wrap contains 2 laser diodes, 4 light emitting diodes and 1 or 2 electrolytic nerve stimulation gel pads.

Once the wraps are in place, the control unit provides up to 30 mins of simultaneous TENS, low-level laser (LLLT) and light-emitting diode (LED) therapy. However, there is a lack of evidence regarding the effectiveness of the Neurolumen device for the treatment of Morton’s neuroma or any other indications.

An Up To Date review on “on Peripheral Nerve Tumors” (Gilchrist and Donahue, 2013) states that “Morton neuroma is a subject of controversy regarding its nomenclature, pathology, and appropriate treatment. Abnormalities ascribed to Morton neuroma are typically located between the metatarsals of the third and fourth toes or at the bifurcation of the fourth plantar digital nerve. The lesions look like a traumatic neuroma grossly, and are comprised of degenerated and/or demyelinated axons, vascular hyalinization, and fibrosis.

Clinical manifestations can include pain and tenderness, but similar lesions are common in patients who are asymptomatic. Surgical removal is advocated by some authors for those who fail conservative measures, but data are limited regarding the effectiveness of surgical and nonsurgical interventions for Morton neuroma”.

Furthermore, an Up To Date review on “Overview of running injuries of the lower extremity (Callahan, 2013) does not mention the use of electrical stimulation or laser therapy as therapeutic options for Morton’s neuroma. Non-Invasive/No-Incision Pain Procedure (NIP) Device: According to the Fix Pain website, the NIP Procedure refers to “Non-Invasive, or No-Incision Pain” Procedure.

It is FDA-cleared/certified for various types of chronic pain (arthritis, cancer pain, cervical pain, fibromyalgia, joint pain, low back pain, migraines, post-operative pain, and sciatica) and other conditions (e.g., anxiety, depression and insomnia).

The microchip NIP Procedure™ device is placed behind the ear of the patient, the acupuncture in corresponding points and the pulses are transmitted through the stimulating needle. With the help of the NIP Procedure™ device, the patients are receiving continuous treatment for 4 to 5 days.

It is recommended that therapies be applied for up to 9 weeks. However, there is a lack of evidence regarding the effectiveness of the NIP Procedure device for the treatment of chronic pain or any other indications.

Electro-Analgesia Treatment (EAT)Electro-Analgesia Treatment (EAT) has been described as nerve block injections followed by electrical stimulation administered with the Synaptic device, and has been used as a treatment for diabetic peripheral neuropathy. The combination of nerve block therapy and electrical stimulation is referred to as Electro-Analgesia Treatment or EAT. The manufacturer states that the Synaptic 4000 treatment is controlled by the patient using a joystick.

According to the manufacturer, electrical stimulation with the Synaptic device is different from other forms of electrical stimuation: “The Synaptic technology is unique and stands apart from all other electrical neuro-stimulation devices such as TENS, EMS, functional electrical stimulation (FES), sacral nerve stimulation (SNS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), spinal cord stimulation (SCS) and cochlear and ocular implants.” The manufacturer explains: “The frequency range is from 40,000 to 400 Hertz.

Conventional modalities have a frequency range of only 500-180 Hertz and begin their activity at the low end of the range increasing to their maximum as controls are elevated. In contrast, Synaptic begins its frequency sweep at the maximum (40,000 Hertz) and as the remote is advanced the frequency decreases to the minimum (400 Hertz).

This cycle may be repeated during each of the ten intensity levels.”The manufacturer states that the waveform of the Synaptic is also unique. “Also protected are the A-waveform, the unique mechanism for SEA energy delivery as well as the method of patient-controlled treatment using a joystick.

The waveform developed for SEA technology mimics a biological process. It simulates the action potential responsible for producing electrical activity in the neuron using a fast rise time and a slow decay, reproducing the action potential in humans.”There are a lack of peer-reviewed published studies of Electro-Analgesia Treatment or of the Synaptic electrical stimulation device. Variable Muscle Stimulators (VMS): Variable muscle stimulators (VMS), like TENS units, produce bi-phasic waves.

However, TENS units produce asymmetric bi-phasic waves, whereas VMS units produce symmetrical bi-phasic waves. Unlike TENS, VMS is used to do FES. However, there is a lack of evidence regarding the clinical effectiveness of VMS. Cefaly: The Cefaly transcutaneous supraorbital nerve stimulator, classified as a transcutaneous electrical nerve stimulator, has an FDA approved indication which is limited to the prophylactic treatment of episodic migraine in individuals 18 years of age or older.

Cefaly is a plastic, battery-powered transcutaneous electrical nerve stimulator worn like a headband with reusable self-adhesive electrodes placed on the forehead to cover the supratrochlear and supraorbital nerves (branches of the trigeminal nerve). The device purportedly works through neuromodulatory effects on those nerves, thereby blocking pain signals.

Quell Device: A recently FDA cleared device, the Quell device, is the first electrical stimulator to receive approval for use during sleep. The device consists of a band worn around the upper calf to theoretically provide systemic relief of chronic pain and is controlled by an individual’s smartphone or tablet.

Combination Therapies: A more recent approach to electrical stimulation has been development of devices that may use a combination of different stimulation modalities, such as combining TENS with ICS, TENS with ultrasound, TENS with low level laser therapy (LLLT) or TENS with neuromuscular stimulation (NMES).

Examples of combination devices include, but may not be limited to, the Neurolumen device (combines TENS with LLLT and light-emitting diode (LED) therapy) or the Empi Phoenix and QB1 System (combination TENS with NMES devices). Additionally, combined ICS and muscle stimulation utilize ICS for pain and muscle stimulation to treat underlying muscle conditions.

Examples of this type of device are the RS-4i sequential stimulator and the EMSI TENS/EMS-14. In combined therapy which consists of high frequency electrical stimulation and peripheral nerve block (also referred to as combination electrochemical therapy, combination electrochemical treatment, or CET), it is purported to treat peripheral neuropathy by first injecting the peripheral nerve with a local anesthetic, followed by a high frequency electrical stimulation.

SENSUS Device: The SENSUS device uses transcutaneous electromagnetic nerve stimulation to purportedly treat individuals with diabetic peripheral neuropathy.

Galvanic Stimulation for Peripheral Arterial Disease: Williams et al (2017) noted that PAD is common and symptoms can be debilitating and lethal. Risk management, exercise, radiological and surgical intervention are all valuable therapies, but morbidity and mortality rates from this disease are increasing. Circulatory enhancement can be achieved using simple medical electronic devices, with claims of minimal adverse side effects.

The evidence for these is variable, prompting a review of the available literature. Embase and Medline were interrogated for full text articles in humans and written in English. Any external medical devices used in the management of PAD were included if they had objective outcome data.

A total of 31 papers met inclusion criteria, but protocols were heterogeneous. The medical devices reported were intermittent pneumatic compression (IPC), NMES or EMS, and galvanic electrical dressings. In patients with intermittent claudication, IPC devices increase popliteal artery velocity (49 to 70 %) and flow (49 to 84 %). Gastrocnemius EMS increased superficial femoral artery flow by 140 %. Over 4.5 to 6 months IPC increased intermittent claudication distance (ICD) (97 to 150 %) and absolute walking distance (AWD) (84 to 112 %), with an associated increase in quality of life; NMES of the calf increased ICD and AWD by 82 % and 61 to 150 % at 4 weeks, and 26 % and 34 % at 8 weeks.

In patients with critical limb ischemia (CLI), IPC reduced rest pain in 40 to 100 % and was associated with ulcer healing rates of 26 %; IPC had an early limb salvage rate of 58 to 83 % at 1 to 3 months, and 58 to 94 % at 1.5 to 3.5 years.

No studies have reported the use of EMS or NMES in the management of CLI. The authors concluded that there is evidence to support the use of IPC in the management of claudication and CLI. There is a building body of literature to support the use of electrical stimulators in PAD, but this is low level to date.

Devices may be of special benefit to those with limited exercise capacity, and in non-reconstructable CLI. Moreover, they stated that galvanic stimulation is not recommended. Appendix TENS Unit Supplies A 4-lead TENS unit may be used with either 2 leads or 4 leads, depending on the characteristics of the member's pain.

If it is ordered for use with 4 leads, the medical record must document why 2 leads are insufficient to meet the member's needs.

If 2 TENS leads are medically necessary, then a maximum of 1 unit of a TENS supply allowance (HCPCS Code A4595) would be considered medically necessary per month; if 4 TENS leads are necessary, a maximum of 2 units per month would be considered medically necessary. If the use of the TENS unit is less than daily, medical necessity of the TENS supply allowance is reduced proportionally. Note: A TENS supply allowance (HCPCS code A4595) includes electrodes (any type), conductive paste or gel (if needed, depending on the type of electrode), tape or other adhesive (if needed, depending on the type of electrode), adhesive remover, skin preparation materials, batteries (9 volt or AA, single use or rechargeable), and a battery charger (if rechargeable batteries are used).

Replacement of lead wires more often than every 12 months is rarely medically necessary. For ongoing supplies and rental DME items, in addition to information described above that justifies the initial provision of the item (s) and/or supplies, there must be information in the member's medical record to support that the item continues to be used by the member and remains medically necessary.

CPT Codes / HCPCS Codes / ICD-10 Codes Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by ""+"": Information in the [brackets] below has been added for clarification purposes.

Codes requiring a 7th character are represented by ""+"": Code Code Description Transcutaneous Electrical Nerve Stimulators (TENS): CPT codes covered if selection criteria are met:64550 Application of surface (transcutaneous) neurostimulator Other CPT codes related to the CPB:97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)97032 Application of a modality to one or more areas; electrical stimulation, (manual), each 15 minutes HCPCS codes covered if selection criteria are met: A4556 Electrodes (e.g., apnea monitor), per pair A4557 Lead wires (e.g., apnea monitor), per pair A4558 Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz.

A4595 Electrical stimulator supplies, 2 lead, per month, (e.g. TENS, NMES)E0720 Transcutaneous electrical nerve stimulation (TENS) device, 2 lead, localized stimulation [not covered for Sensus]E0730 Transcutaneous electrical nerve stimulation (TENS) device, 4 or more leads, for multiple nerve stimulation [not covered for Sensus]ICD- 10 codes covered if selection criteria are met: G89.18 Other acute postprocedural pain [not covered for post- total knee arthroplasty pain]G89.21 - G89.29 Chronic pain G89.4 Chronic pain syndrome ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): E08.40 - E08.42 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, mononeuropathy, and polyneuropathy [not covered for SENSUS]E09.40 - E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy unspecified, mononeuropathy, and polyneuropathy [not covered for SENSUS]E10.40 - E10.42 Type 1 diabetes mellitus with diabetic neuropathy, unspecified, mononeuropathy, and polyneuropathy [not covered for SENSUS]E11.40 - E11.42 Type 2 diabetes mellitus with diabetic neuropathy, unspecified, mononeuropathy, and polyneuropathy [not covered for SENSUS]E13.40 - E13.42 Other specified diabetes mellitus with diabetic neuropathy, unspecified, mononeuropathy, and polyneuropathy [not covered for SENSUS]G43.001 - G43.919 Migraine G44.001 - G44.89 Other headache syndromes G62.0 Drug- induced polyneuropathy [chemotherapy- induced peripheral neuropathy]G54.6 Phantom limb syndrome with pain G89.11 Acute pain due to trauma [hip fractures]I73.9 Peripheral vascular disease, unspecified M26.602 - M26.609 Temporomandibular joint disorders M54.40 - M54.5 Lumbago M75.00 - M75.02 Adhesive capsulitis of shoulder M75.30 - M75.32 Calcific tendinitis of shoulder M75.40 - M75.42 Impingement syndrome of shoulder M75.50 - M75.52 Bursitis of shoulder [rotator cuff tendinitis]M79.7 Fibromyalgia N94.0 - N94.9 Pain and other conditions associated with female genital organs and menstrual cycle R10.0 - R10.13R10.30 - R10.33Abdominal pain R51 Headache T20.00x A – T32.99 Burns and corrosions T87.9 Unspecified complications of amputation stump [stump pain]Form- fitting Conductive Garment: HCPCS codes covered if selection criteria are met: E0731 Form- fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)ICD- 10 codes covered if selection criteria are met (not all- inclusive): M62.50 - M62.59 Muscular wasting and atrophy, not elsewhere classified M62.84 Sarcopenia Interferential Stimulation: No specific codes HCPCS codes not covered for indications listed in the CPB: S8130 Interferential current stimulator, 2 channel S8131 Interferential current stimulator, 4 channel Percutaneous Electrical Nerve Stimulation (PENS): CPT codes covered if selection criteria are met: Percutaneous Electrical Nerve Stimulation (PENS) - no specific code: Other HCPCS codes related to the CPB:: S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one- on one contact with the patient ICD- 10 codes covered if selection criteria are met: G56.00 - G58.9 Mononeuropathies of upper and lower limbs M51.04 - M51.06 Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders with myelopathy M51.24 - M51.37 Other thoracic, thoracolumbar and lumbosacral intervertebral disc displacement and degeneration M54.10 - M54.18 Radiculopathy M54.30 - M54.32 Sciatica M54.40 - M54.42 Lumbago with sciatica M54.5 Low back pain [lumbago]M54.6 Pain in thoracic spine M79.2 Neuralgia and neuritis, unspecified [neuropathic pain]M96.1 Postlaminectomy syndrome, lumbar region ICD- 10 codes not covered for indications listed in the CPB: M47.11 - M47.13M47.811 - M47.813Cervical spondylosis [with or without myelopathy]M48.01 - M48.03 Spinal stenosis [cervical region]M50.00 - M50.03 Cervical disc disorder with myelopathy M50.20 - M50.23 Other cervical disc displacement M50.30 - M50.33 Other cervical disc degeneration M50.80 - M50.83 Other cervical disc disorders M50.90 - M50.93 Cervical disc disorder, unspecified M96.1 Postlaminectomy syndrome, not elsewhere classified [cervical region]Scrambler Therapy/Calmare Therapy Device: CPT codes not covered for indications listed in the CPB (not all- inclusive):0278T Trancutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes) [Calmare therapy device]ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): G89.21 - G89.29 Chronic pain G89.3 Neoplasm related pain (acute) (chronic)Non- Invasive Interactive Neurostimulation: No specific code ICD- 10 codes not covered for indications listed in the CPB: M17.0 - M17.9 Osteoarthritis of knee M54.2 Cervicalgia M84.471 - M84.473 Pathological fracture, left, right, or unspecified ankle Peripheral Subcutaneous Field Stimulation: CPT codes not covered for indications listed in the CPB:0282T Percutaneous or open implantation of neurostimulator electrode array (s), subcutaneous (peripheral subcutaneous filed stimulation), including imaging guidance, when performed, cervical, thoracic or lumbar; for trial, including removal at the conclusion of trial period0283T permanent, with implantation of a pulse generator0284T Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed0285T Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed ICD- 10 codes not covered for indications listed in the CPB: I20.0 Unstable angina I20.1 - I20.09 Angina pectoris R20.0 - R20.9 Disturbances of skin sensation Peripherally Implanted Nerve Stimulators: CPT codes covered if selection criteria are met:64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator64575 peripheral nerve (excludes sacral nerve)64585 Revision or removal of peripheral neurostimulator electrodes64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver Other CPT codes related to the CPB:95860 - 95872 Electromyography95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method HCPCS codes covered if selection criteria are met: L8680 Implantable neurostimulator electrode, each L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only L8682 Implantable neurostimulator radiofrequency receiver L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension L8686 Implantable neurostimulator pulse generator, single array, non- rechargeable, includes extension L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension L8688 Implantable neurostimulator pulse generator, dual array, non- rechargeable, includes extension L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only ICD- 10 codes covered if selection criteria are met: G56.00 - G59 Mononeuropathies G90.50 - G90.59 Complex regional pain syndrome I (CRPS I)S14.101S - S14.159SS14.2xx S - S14.9xx SS24.101S - S24.159SS24.2xx S - S24.9xx SS34.101S - S34.139SS34.21x S - S34.9xx SS44.8x1S - S44.92x SS54.8x1S - S54.92x SS64.8x1S - S64.92x SS74.8x1S - S74.92x SS84.801S - S84.92x SS94.8x1S - S94.92x SSpinal cord injury, injury to nerve root (s), spinal plexus (s), and other nerves of trunk, injury to peripheral nerve of shoulder girdle and upper limb, or injury to peripheral nerve of pelvic girdle and lower limb, sequela S14.2xx+ - S14.9xx+S24.101+ - S24.159+S24.2xx+ - S24.9xx+S34.101+ - S34.139+S34.21x+ - S34.9xx+S44.8x1+ - S44.92x+S54.8x1+ - S54.92x+S64.8x1+ - S64.92x+S74.8x1+ - S74.92x+S84.801+ - S84.92x+S94.8x1+ - S94.92x+Injury to nerve roots and spinal plexus, injury to other nerve (s) of trunk, excluding shoulder and pelvic girdles, injury to peripheral nerve (s) of shoulder girdle and upper limb, or injury to peripheral nerve (s) of pelvic girdle and lower limb ICD- 10 codes not covered for indications listed in the CPB: B02.23 Postherpetic polyneuropathy F11.90 - F19.99 Drug dependence disorders H- Wave Type Stimulators: HCPCS codes not covered if selection criteria are met: E0745 Neuromuscular stimulator; electronic shock unit [ H- Wave stimulator]ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): E08.49,E09.49,E10.49,E11.49, E13.49Diabetes mellitus with other diabetic neurological complication Intramuscular stimulation: CPT codes not covered for indications listed in the CPB:64565 Percutaneous implantation of neurostimulator electrodes; neuromuscular64580 Incision for implantation of neurostimulator electrodes; neuromuscular ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): M25.50 - M25.579 Pain in joint M54.10 Radiculopathy [radiculitis]M60.80 - M60.9 Other and unspecified myositis M79.1 Myalgia M79.2 Neuralgia and neuritis, unspecified Sympathetic Therapy: No specific codes Electroceutical Therapy: No specific codes Transcutaneous electrical joint stimulation devices (Bioni Care): HCPCS codes not covered for indications listed in the CPB: E0762 Transcutaneous electrical joint stimulation device system, includes all accessories ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): S93.401+ - S93.499+ Sprain of ankle Electro- Acuscope Myopulse Therapy: No specific codes Electrical stimulation of sacral roots or lumbosacral plexus: CPT codes not covered for indications listed in the CPB:64555 Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve)64561 sacral nerve (transforaminal placement) including image guidance, if performed64575 Incision for implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve)64581 sacral nerve (transforaminal placement)ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): R10.0 - R10.13R10.30 - R10.33Abdominal pain R10.811 - R10.829 Abdominal tenderness R19.8 Other specified symptoms and signs involving the digestive system and abdomen Microcurrent Therapy: No specific codes ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): M54.5 Low back pain [lumbago]M54.9 Dorsalgia, unspecified Pulse Stimulation [P- Stim]: HCPCS codes not covered for indications listed in the CPB (not all- inclusive): S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one- on- one contact with the patient [P- STIM device]ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): B02.21 - B02.29 Zoster with other nervous system involvement M17.0 - M17.9 Osteoarthritis of knee M51.14 - M54.17 Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders with radiculopathy M54.10 - M54.2 Radiculopathy M54.5 Low back pain M62.830 Muscle spasm of back [cervical, lumbar]M96.1 Post laminectomy syndrome [failed back]Neurolumen device: No specific code ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): E08.40,E08.42,E09.40,E09.42,E10.40,E10.42,E11.40,E11.42,E13.40, E13.42Polyneuropathy in diabetes G57.60 - G57.63 Lesion of plantar nerve [Morton's neuroma]G60.0 - G60.9 Hereditary and idiopathic neuropathy Non- invasive/no- incision pain procedure (NIP) device: No specific code ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): F32.9 Major depressive disorder, single episode, unspecified F41.9 Anxiety disorder, unspecified G43.001 - G43.919 Migraine G47.00 - G47.09 Insomnia G89.18 Other acute postprocedural pain G89.3 Neoplasm related pain (acute) (chronic)M12.00 - M12.9 Other and unspecified arthropathy M25.50 - M25.579 Pain in joint M54.2 Cervicalgia M54.30 - M54.5 Sciatica and low back pain M60.80 - M60.9 Myositis M79.1 Myalgia Electro- Analgesia Treatment (EAT) using the Synaptic electrical stimulator: No specific code Other CPT codes related to the CPB:64450 Injection, anesthetic agent, other peripheral nerve or branch ICD- 10 codes not covered for indications listed in the CPB (not all inclusive): E08.40,E08.42,E09.40,E09.42,E10.40,E10.42,E11.40,E11.42,E13.40, E13.42Polyneuropathy in diabetes G60.0 Hereditary motor and sensory neuropathy G60.8 Other hereditary and idiopathic neuropathies Cefaly transcutaneous electrical stimulator headband: ICD- 10 codes not covered for indications listed in the CPB (not all inclusive): G43.001 - G43.919 Migraines Percutaneous neuromodulation therapy: No specific code ICD- 10 codes not covered for indications listed in the CPB (not all inclusive): G89.0 - G89.4 Pain, not elsewhere classified Variable Neuromuscular Stimulation – see CPB 677: The Quell device: No specific code Combination electrochemical therapy/treatment (CET): No specific code Galvanic stimulation and other types of electrical stimulation: CPT codes not covered for indications listed in the CPB:97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)97032 Application of a modality to one or more areas; electrical stimulation, (manual), each 15 minutes HCPCS codes not covered for indications listed in the CPB (not all- inclusive): E0745 Neuromuscular stimulator, electronic shock unit ICD- 10 codes not covered for indications listed in the CPB (not all inclusive): I73.9 Peripheral vascular disease, unspecified The above policy is based on the following references: TENS/PENS: Ventafridda V, et al.

Transcutaneous stimulation in cancer pain. In: Advances in Pain Research and Therapy. Vol. 2. JJ Bonica, V Ventafridda, eds.

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Stereotact Funct Neurosurg. 1991;56 (1):2-19. Agency for Healthcare Policy and Research (AHCPR), Acute Pain Management Guideline Panel. Acute pain management: Operative or medical procedures and trauma. Clinical Practice Guideline No. 1. AHCPR Publication No. 92-0032. Rockville, MD: AHCPR; February 1992. Lander J, Fowler-Kerry S. TENS for children's procedural pain. Pain. 1993;52 (2):209-216. Jacox A, Carr DB, Payne R, et al. Management of cancer pain. Clinical Practice Guideline No.

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Julka IS, Alvaro M, Kumar D. Beneficial effects of electrical stimulation on neuropathic symptoms in diabetes patients. J Foot Ankle Surg. 1998;37 (3):191-194. Mc Dowell BC, Mc Cormack K, Walsh DM, et al. Comparative analgesic effects of H-wave therapy and transcutaneous electrical nerve stimulation on pain threshold in humans.

Arch Phys Med Rehabil. 1999;80 (9):1001-1004. Blum K, Chen AL, Chen TJ, et al. The H-Wave device is an effective and safe non-pharmacological analgesic for chronic pain: A meta-analysis. Adv Therapy. 2008;25 (7):644-657. Centre for Reviews and Dissemination (CRD). The H-wave device is an effective and safe non-pharmacological analgesic for chronic pain: A meta-analysis. Database of Abstracts of Reviews of Effectiveness. York, UK: University of York; 2009. Peripheral Nerve Stimulation: Cauthen JC, Renner EJ. Transcutaneous and peripheral nerve stimulator for chronic pain states. Surg Neurol. 1975;4 (1):102-104.

Meyerson BA, Hakansson J. Alleviation of atypical trigeminal pain by stimulation of the Gasserian ganglion via an implanted electrode. Acta Neurochir Suppl (Wien). 1980;30:303-309. Racz GB, Browne T, Lewis R Jr. Peripheral stimulator implant for treatment of causalgia caused by electrical burns.

Tex Med. 1988;84 (11):45-50. Leak WD, Ansel AE. Neural stimulation: Spinal cord and peripheral nerve stimulation. In: Pain Medicine. A Comprehensive Review. PP Raj, ed. St. Louis, MO: Mosby; 1996; Ch. 32: 327-333. Taub E, Munz M, Tasker RR. Chronic electrical stimulation of the gasserian ganglion for the relief of pain. J Neurosurg. 1997;86 (2):197-202. American Society of Addiction Medicine (ASAM). Definitions related to the use of opoids for the treatment of pain.

Public Policy of ASAM. Chevy Chase, MD: ASAM; February 2001. Available at: http://www.asam.org/ppol/ paindef.htm. Accessed September 9, 2004. Slavin KV. Peripheral nerve stimulation for the treatment of neuropathic craniofacial pain.

Acta Neurochir Suppl. 2007;97 (Pt 1):115-120. Deer T, Pope J, Benyamin R, et al. Prospective, multicenter, randomized, double-blinded, partial crossover study to assess the safety and efficacy of the novel neuromodulation system in the treatment of patients with chronic pain of peripheral nerve origin. Neuromodulation. 2016;19:91-100. Intramuscular Stimulation: Chu J. Twitch-obtaining intramuscular stimulation (TOIMS) in acute partial radial nerve palsy.

Electromyogr Clin Neurophysiol. 1999;39 (4):221-226. Chu J. The role of the monopolar electromyographic pin in myofascial pain therapy: Automated twitch-obtaining intramuscular stimulation (ATOIMS) and electrical twitch-obtaining intramuscular stimulation (ETOIMS).

Electromyogr Clin Neurophysiol. 1999;39 (8):503-511. Chu J. Early observations in radiculopathic pain control using electrodiagnostically derived new treatment techniques: Automated twitch-obtaining intramuscular stimulation (ATOIMS) and electrical twitch-obtaining intramuscular stimulation (ETOIMS). Electromyogr Clin Neurophysiol. 2000;40 (4):195-204. Chu J, Gozon BS, Schwartz I. Twitch-obtaining intramuscular stimulation in reflex sympathetic dystrophy. Electromyogr Clin Neurophysiol. 2002;42 (5):259-266. Sympathetic Therapy (Dynatron): Dynatronics Corp. Dynatron Sympathetic Therapy System (STS): Revolutionary Breakthrough in the Treatment of Pain [website].

Salt Lake City, UT: Dynatronics; 2001. Available at: http://www.chronicpainrx.com/dynatron/. Accessed January 14, 2002. Rajala Rehab Products. Sympathetic Therapy System [website]. Pleasanton, CA: Rajala; 2001. Available at: http://www.rajala.com/cgi/catalog.pl? Electrotherapy. Accessed January 14, 2001. Guido EH. Effects of sympathetic therapy on chronic pain in peripheral neuropathy subjects.

Am J Pain Mgmt. 2002;12:31-34. Hord ED, Oaklander AL. Complex regional pain syndrome: A review of evidence-supported treatment options. Curr Pain Headache Rep. 2003;7 (3):188-196. Washington State Department of Labor and Industries, Office of the Medical Director.

Dynatron STS. Technology Assessment. Olympia, WA: Washington State Department of Labor and Industries; updated April 30, 2002. Available at: http://www.lni.wa.gov/omd/Pdf Doc/DYNATRON.pdf. Accessed August 17, 2003. Work Loss Data Institute. Pain (chronic). Corpus Christi, TX: Work Loss Data Institute; 2008. Electroceutical Therapy: Benchmark Integrative Medicine, LLC. Clinical electroceutical medicine [website]. Fayetteville, GA: Benchmark; 2002. Available at: http://www.benchmarkpain.com/page4.html. Accessed May 10, 2002. Robertson M. Electroceutical nerve block [abstract]. Chronic Pain Solutions, Fall 1998.

Available at: http://www.chronicpainsolutions.com/ nerveblock.htm. Accessed May 22, 2002. Empire Medicare Services NJ. Facet joint nerve block. Medical Policy Bulletin Freedom of Information. Medicare News Brief - New Jersey (Part B). MNB-NJ-2001-2. New York, NY: Empire; April 2001. Available at: http://www.empiremedicare.com/NJBULL/njb2001-2/s129.htm. Accessed May 22, 2002. Empire Medicare Services. Nerve blocks: paravertebral nerve blocks. Medicare Part B Medical Policy.

Policy No. YPF# 180, Ysurg #43. New York, NY: Empire; May 1, 1999. Available at: http://www.empiremedicare.com/Newypolicy/policy/YSRG43r2.htm. Accessed May 22, 2002. GHI Medicare Division. Nerve blocks/ paravertebral nerve blocks. Local Medical Necessity Policy. Policy No. SUR-1233. New York, NY: GHI Medicare; July 30, 1999. Available at: http://www.ghimedicare.com/lmrp2/sur-1233.html. Accessed May 22, 2002. Lake Michigan Medical, Inc. Matrix Biokinetics, Inc. PROGene Sys System Electroceutical Treatment [website].

Chicago, IL: Lake Michigan Medical; 2002. Available at: http://lakemichiganmedical.com.control.interliant.com/Pain_Management9.html. Accessed May 10, 2002. Work Loss Data Institute. Pain (chronic). Corpus Christi, TX: Work Loss Data Institute; 2008. Transcutaneous Electrical Joint Stimulation and Pulsed Electrical Stimulation: Zizic TM, Hoffman KC, Holt PA, et al.

The treatment of osteoarthritis of the knee with pulsed electrical stimulation. J Rheumatol. 1995;22 (9):1757-1761. Hulme J, Robinson V, De Bie R, et al. Electromagnetic fields for the treatment of osteoarthritis.

Cochrane Database Syst Rev. 2002; (1): CD003523. Farr J, Mont MA, Garland D, et al. Pulsed electrical stimulation in patients with osteoarthritis of the knee: Follow up in 288 patients who had failed non-operative therapy. Surg Technol Int. 2006;15:227-233. Mc Carthy CJ, Callaghan MJ, Oldham JA. Pulsed electromagnetic energy treatment offers no clinical benefit in reducing the pain of knee osteoarthritis: A systematic review.

BMC Musculoskelet Disord. 2006;7:51. Garland D, Holt P, Harrington JT, et al. A 3-month, randomized, double-blind, placebo-controlled study to evaluate the safety and efficacy of a highly optimized, capacitively coupled, pulsed electrical stimulator in patients with osteoarthritis of the knee. Osteoarthritis Cartilage. 2007;15 (6):630-637. Fary RE, Carroll GJ, Briffa TG, et al. The effectiveness of pulsed electrical stimulation (E-PES) in the management of osteoarthritis of the knee: A protocol for a randomised controlled trial.

BMC Musculoskelet Disord. 2008;9:18. NHIC, Corp. Draft LCD for transcutaneous electrical joint stimulation devices. LCD ID No. DL28551. Durable Medical Equipment (DME) Medicare Administrative Carrier (MAC) Jurisdiction A. Hingham, MA: NHIC; 2008. Rutjes AWS, Nüesch E, Sterchi R, et al. Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database Syst Rev. 2009; (4): CD002823. Mendel FC, Dolan MG, Fish DR, et al. Effect of high-voltage pulsed current on recovery after grades I and II lateral ankle sprains. J Sport Rehabil. 2010;19 (4):399-410. Fary RE, Carroll GJ, Briffa TG, Briffa NK. The effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee: Results of a double-blind, randomized, placebo-controlled, repeated-measures trial. Arthritis Rheum. 2011;63 (5):1333-1342. Lumbosacral Plexus and Sacral Nerve Root Stimulation: Alo KM, Yland MJ, Redko V, et al. Lumbar and sacral nerve root stimulation (NRS) in the treatment of chronic pain: A novel anatomic approach and neuro stimulation technique. Neuromodulation. 1999;2 (1):23-31Falco FJE, Rubbani M, Heinbaugh J. Anterograde sacral nerve root stimulation (ASNRS) via the sacral hiatus: Benefits, limitations, and percutaneous implantation technique. Neuromodulation. 2003;6 (4):219-224. Siegel S, Paszkievics E, Kirkpatrick C et al. Sacral nerve stimulation in patients with chronic intractable pelvic pain. J Urol . 2001;166 (5):1742-1745. Kim P. Advanced pain management techniques: An overview of neurostimulation. Expert Column. Medscape Neurol Neurosurg. 2004;6 (1). Available at: http://www.medscape.com/viewarticle/473431. Accessed January 6, 2006. Microcurrent Therapy: Koopman JS, Vrinten DH, van Wijck AJ. Efficacy of microcurrent therapy in the treatment of chronic nonspecific back pain: A pilot study. Clin J Pain. 2009;25 (6):495-499. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: A review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009;34 (10):1078-1093. Zuim PR, Garcia AR, Turcio KH, Hamata MM. Evaluation of microcurrent electrical nerve stimulation (MENS) effectiveness on muscle pain in temporomandibular disorders patients. J Appl Oral Sci. 2006;14 (1):61-66. Gossrau G, Wähner M, Kuschke M, et al. Microcurrent transcutaneous electric nerve stimulation in painful diabetic neuropathy: A randomized placebo-controlled study. Pain Med. 2011;12 (6):953-960. Scrambler Therapy/The Calmare Therapy Device: Marineo G. Untreatable pain resulting from abdominal cancer: New hope from biophysics? JOP. 2003;4 (1):1-10. Sabato AF, Marineo G, Gatti A. Scrambler therapy. Minerva Anestesiol. 2005;71 (7-8):479-482. Smith TJ, Coyne PJ, Parker GL, et al. Pilot trial of a patient-specific cutaneous electrostimulation device (MC5-A Calmare®) for chemotherapy-induced peripheral neuropathy. J Pain Symptom Manage. 2010;40 (6):883-891. Ricci M, Pirotti S, Scarpi E, et al. Managing chronic pain: Results from an open-label study using MC5-A Calmare® device. Support Care Cancer. 2012;20 (2):405-12Marineo G, Iorno V, Gandini C, et al. Scrambler therapy may relieve chronic neuropathic pain more effectively than guideline-based drug management: Results of a pilot, randomized, controlled trial. J Pain Symptom Manage. 2012;43 (1):87-95. Smith TJ, Marineo G. Treatment of postherpetic pain wth Scrambler therapy, a patient-specific neurocutaneous electrical stimulation device. Am J Hosp Palliat Care. 2013 Jul 8 [Epub ahead of print]. Pachman DR, Watson JC, Loprinzi CL. Therapeutic strategies for cancer treatment related peripheral neuropathies. Curr Treat Options Oncol. 2014;15 (4):567-580. Starkweather AR, Coyne P, Lyon DE, et al. Decreased low back pain intensity and differential gene expression following Calmare®: Results from a double-blinded randomized sham-controlled study. Res Nurs Health. 2015;38 (1):29-38. Pachman DR, Weisbrod BL, Seisler DK, et al. Pilot evaluation of Scrambler therapy for the treatment of chemotherapy-induced peripheral neuropathy. Support Care Cancer. 2015;23 (4):943-951. Majithia N, Smith TJ, Coyne PJ, et al. Scrambler therapy for the management of chronic pain. Support Care Cancer. 2016;24 (6):2807-2814. Notaro P, Dell'Agnola CA, Dell'Agnola AJ, et al. Pilot evaluation of scrambler therapy for pain induced by bone and visceral metastases and refractory to standard therapies. Support Care Cancer. 2016;24 (4):1649-1654. Smith T, Cheville AL, Loprinzi CL, Longo-Schoberlein D. Scrambler therapy for the treatment of chronic post-mastectomy pain (c PMP). Cureus. 2017;9 (6):e1378. Peripheral Subcutaneous Field Stimulation: Falco FJ, Berger J, Vrable A, et al. Cross talk: A new method for peripheral nerve stimulation. An observational report with cadaveric verification. Pain Physician. 2009;12 (6):965-983. Mc Roberts WP, Roche M. Novel approach for peripheral subcutaneous field stimulation for the treatment of severe, chronic knee joint pain after total knee arthroplasty. Neuromodulation. 2010;13 (2):131-136. Yakovlev AE, Resch BE. Treatment of chronic intractable atypical facial pain using peripheral subcutaneous field stimulation. Neuromodulation. 2010;13 (2):137-140. Yakovlev AE, Resch BE, Karasev SA. Treatment of intractable hip pain after THA and GTB using peripheral nerve field stimulation: A case series. WMJ.2010;109 (3):149-152. Ricciardo B, Kumar S, O'Callaghan J, Boyce Z. Peripheral nerve field stimulation for pruritus relief in a patient with notalgia paraesthetica. Australas J Dermatol. 2010;51 (1):56-59. Goroszeniuk T, Pang D, Al-Kaisy A, Sanderson K. Subcutaneous target stimulation-peripheral subcutaneous field stimulation in the treatment of refractory angina: Preliminary case reports. Pain Pract. 2012;12 (1):71-79. Burgher AH, Huntoon MA, Turley TW, et al. Subcutaneous peripheral nerve stimulation with inter-lead stimulation for axial neck and low back pain: Case series and review of the literature. Neuromodulation. 2012;15 (2):100-106; discussion 106-107. Electro Therapeutic Point Stimulation: Hocking B. Healing pain with ETPS therapy. Available at: http://www.alaskawellness.com/Hocking May June2006.htm. Accessed October 19, 2012. Aliyev RM, Geiger G. Cell-stimulation therapy of lateral epicondylitis with frequency-modulated low-intensity electric current. Bull Exp Biol Med. 2012;152 (5):653-655. Pulsed Stimulation (e.g., P-Stim): Sator-Katzenschlager SM, Szeles JC, Scharbert G, et al. Electrical stimulation of auricular acupuncture points is more effective than conventional manual auricular acupuncture in chronic cervical pain: A pilot study. Anesth Analg. 2003;97 (5):1469-1473. Sator-Katzenschlager SM, Scharbert G, Kozek-Langenecker SA, et al. The short- and long-term benefit in chronic low back pain through adjuvant electrical versus manual auricular acupuncture. Anesth Analg. 2004;98 (5):1359-1364,Sator-Katzenschlager SM, Michalek-Sauberer A. P-Stim auricular electroacupuncture stimulation device for pain relief. Expert Rev Med Devices. 2007;4 (1):23-32. Michalek-Sauberer A, Heinzl H, Sator-Katzenschlager SM, et al. Perioperative auricular electroacupuncture has no effect on pain and analgesic consumption after third molar tooth extraction. Anesth Analg. 2007;104 (3):542-547. Wang SM. An integrative approach for treating postherpetic neuralgia -- a case report. Pain Pract. 2007;7 (3):274-278. Holzer A, Leitgeb U, Spacek A, et al. Auricular acupuncture for postoperative pain after gynecological surgery: A randomized controlled trail. Minerva Anestesiol. 2011;77 (3):298-304. Fary RE, Carroll GJ, Briffa TG, Briffa NK. The effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee: Results of a double-blind, randomized, placebo-controlled, repeated-measures trial. Arthritis Rheum. 2011;63 (5):1333-1342. Neurolumen Device: Gilchrist JM, Donahue JE. Peripheral nerve tumors. Up To Date [online serial]. Waltham, MA: Up To Date; reviewed February 2013. . Callahan LR. Overview of running injuries of the lower extremity. Up To Date [online serial]. Waltham, MA: Up To Date; reviewed November 2013. Synaptic Device: Synaptic Corp. Drug Free, Non-Invasive Solution to Pain. Synaptic Brochure. Denver, CO: Synaptic; 2010. Available at http://www.assureddrugtesting.com/images/Synaptic-Brochure-2010.pdf. Accessed February 10, 2014. Electrotherapy for the Treatment of Adhesive Capsulitis (Frozen Shoulder): Page MJ, Green S, Kramer S, et al. Electrotherapy modalities for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;10: CD011324. Non-Invasive Interactive Neurostimulation (Inter X 1000 Neurostimulator Device): Selfe TK, Bourguignon C, Taylor AG. Effects of noninvasive interactive neurostimulation on symptoms of osteoarthritis of the knee: A randomized, sham-controlled pilot study. J Altern Complement Med. 2008;14 (9):1075-1081. Gorodetskyi IG, Gorodnichenko AI, Tursin PS, et al. Use of noninvasive interactive neurostimulation to improve short-term recovery in patients with surgically repaired bimalleolar ankle fractures: A prospective, randomized clinical trial. J Foot Ankle Surg. 2010;49 (5):432-437. Lin CW, Donkers NA, Refshauge KM, et al. Rehabilitation for ankle fractures in adults. Cochrane Database Syst Rev. 2012;11: CD005595. Teodorczyk-Injeyan JA, Triano JJ, Mc Gregor M, et al. Effect of interactive neurostimulation therapy on inflammatory response in patients with chronic and recurrent mechanical neck pain. J Manipulative Physiol Ther. 2015;38 (8):545-554. Cefaly: Riederer F, Penning S, Schoenen J. Transcutaneous supraorbital nerve stimulation (t-SNS) with the Cefaly (®) device for migraine prevention: A Review of the Available Data. Pain Ther. 2015;4 (2):135-147. Didier HA, Di Fiore P, Marchetti C, et al. Electromyography data in chronic migraine patients by using neurostimulation with the Cefaly® device. Neurol Sci. 2015;36 Suppl 1:115-119. A transcutaneous electrical nerve stimulation device (Cefaly) for migraine prevention. Med Lett Drugs Ther. 2014;56 (1449):78. Magis D, Sava S, d'Elia TS, et al. Safety and patients' satisfaction of transcutaneous supraorbital neurostimulation (t SNS) with the Cefaly® device in headache treatment: a survey of 2,313 headache sufferers in the general population. J Headache Pain. 2013;14:95. Schoenen J, Vandersmissen B, Jeangette S, et al. Migraine prevention with a supraorbital transcutaneous stimulator: A randomized controlled trial. Neurology. 2013;80 (8):697-704. Piquet M, Balestra C, Sava SL, Schoenen JE. Supraorbital transcutaneous neurostimulation has sedative effects in healthy subjects. BMC Neurol. 2011;11:135. Galvanic Stimulation: Williams KJ, Babber A, Ravikumar R, Davies AH. Non-invasive management of peripheral arterial disease. Adv Exp Med Biol. 2017;906:387-406. Policy History Last Review 03/12/2018Effective: 07/31/1995Next Review: 01/10/2019Review History Definitions Additional Information Clinical Policy Bulletin Notes "

des Equipment Guide The information contained in this section will list the top pieces of durable medical equipment that might be needed for a Medicare patient. A description of the equipment, Medicare information about this equipment and other related products will be provided on each page of equipment, where applicable.

"About MED Suppliers Network The MED Suppliers Network is a group of durable medical equipment suppliers who have met the quality standards and accreditation requirements set forth by CMS and were awarded contracts for Competitively Bid items.

Also listed on the site are durable medical equipment suppliers across the nation who can supply product to Medicare patients who are not currently affected by Competitive Bidding. About Medicare Competitive Bidding Program The Medicare Competitive Bidding Program was mandated by Congress through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

The statute requires that Medicare replace the current fee schedule payment methodology for selected Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items with a competitive bid process. The intent is to improve the effectiveness of the Medicare methodology for setting DMEPOS payment amounts, which will reduce beneficiary out-of-pocket expenses and save the Medicare program money while ensuring beneficiary access to quality items and services.

Under the program, a competition among suppliers who operate in a particular competitive bidding area (CBA) was conducted.

Suppliers were required to submit a bid for selected products. Not all products or items are subject to competitive bidding. With the use of this website and its network of durable medical equipment suppliers, consumers, caregivers and healthcare providers will be able to locate a provider to meet their needs for durable medical equipment.

To locate a provider for a patient's needs, please enter the patient zip code in the ""Locate a Supplier by Zip Code"" area or click here. Gui

Diagnoses Guide The information contained in the diagnosis guide section will give you an overview of various diagnoses and the home medical equipment that may be needed for patients diagnosed with the conditions.

This equipment is designed to help improve the quality of life for the patient and the caregiver by helping maintain the patient’s mobility and independence.

Medicare Guide We've included this information to try to help you understand the rules for Medicare coverage for your equipment. Additionally, we have provided frequently asked questions and tips for finding the right home medical equipment provider. Locate a Supplier by Zip Code To locate a provider for a patient’s equipment needs, enter the zip code for the area where the patient resides in the area provided below.

You will be provided a list of providers who can meet the patient’s needs for a variety of durable medical equipment.

Further search capabilities will be available to assist in narrowing down the search by product and or insurance payer. Featured FAQs View All What's covered under Medicare? What is the process for getting equipment through Medicare?

What are my costs under Medicare? Most Recent News View All MED Launches New Legislative Advocacy Site Round 2 Recompete Timeline Announced Round 1 Recompete Contract Suppliers Announced Round 2 Single Payment Amounts Announced Information for traveling patients Video: Competitive Bidding Explanation and Update "

Medicare Part B (Medical Insurance) covers blood sugar monitors as durable medical equipment (DME) that your doctor prescribes for use in your home.

Your Medicare Coverage

Is my test, item, or service covered? Go Blood sugar (glucose) monitors How often is it covered?

Who's eligible? All people with Part B are cover

ed. Your costs in Original Medicare If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways.

. Durable medical equipment. Medicare pays 80 percent of its approved amount for certain pieces of medical equipment, such as a wheelchair or walker. You pay 20 percent coinsurance, and could pay up to 15 percent if your home care provider does not accept Medicare’s approved fees.

Does my mother qualify for home health care?

By —Philip Moeller0 comments Share Does my mother qualify for home health care? Economy May 27, 2015 5:46 PM EDTEditor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.

Moeller is a research fellow at the Center on Aging & Work at Boston College and co- author of “How to Live to 100.” He wrote his latest book, “How to Get What’s Yours: The Secrets to Maxing Out Your Social Security,” with Making Sen$e’s Paul Solman and Larry Kotlikoff. He is now working on a companion book about Medicare. Follow him on Twitter @Phil Moeller or e-mail him at medicarephil@gmail.com. Your Medicare Questions Medicare rules and private insurance plans can affect people differently depending on where they live.

To make sure the answers here are as accurate as possible, Phil is working with the State Health Insurance Assistance Program (SHIP). It is funded by the government but is otherwise independent and trains volunteers to provide consumer Medicare counseling in state and local offices around the country. The nonprofit Medicare Rights Center (MRC) is also providing on-going help. Maria – Penn. : My mom has a Medicare Advantage plan that states that she has 35 hours of home health care.

Unfortunately not one person at her insurer can clarify for me what these hours can be used for when needed. My mom is leaving a rehabilitation center, after having a stroke and broken pelvis and needs a home health aide to assist with bathing, transferring from bed to chair with a lift, changing a bandage from a deep wound, etc.

I know she can use some of these hours for nursing care, physical therapy, and occupational therapy. Can any of these hours be used for home health care as outlined above? GOT MEDICARE QUESTIONS? Ask Phil Here Phil Moeller: I’m sorry to hear about your mom’s health problems and your hassles in trying to find out how to get her the help she needs.

It seems to me, and the experts at the Medicare Rights Center, that your mom qualifies for the type of home health care that you describe.

I’ll explain the detailed requirements but first want to cut to the practical requirement: if you cannot get a straight answer from your mom’s insurer, you will need help. Her doctor’s office needs to take up her cause as well, including signing a statement about her need for the care.

In an ideal world, someone there will know the bureaucratic ropes and help you. Also, you can call the MRC or your local SHIP office or even 1-800-MEDICARE (1-800-633-4227). Your mom’s Medicare Advantage plan has to offer the home health services required by Medicare. Plans are free to offer better benefits than basic Medicare (Parts A and B) but they cannot offer plans with inferior benefits.

Now, for the long answer. Would you expect anything less from Medicare? This comes courtesy of the MRC, and is addressed to the person needing care which, in your case, would be your mom. Medicare will help pay for your home care if all four of the following are true:1. You are considered homebound.

Medicare considers you homebound if you meet the following criteria: You need the help of another person or special equipment (walker, wheelchair, crutches, etc.) to leave your home or your doctor believes that leaving your home would be harmful to your health; and It is difficult for you to leave your home and you typically cannot do so.2.

You need skilled care. This includes skilled nursing care on an intermittent basis. Intermittent means you need care as little as once every 60 days to as much as once a day for three weeks (this period can be longer if you need more care but your need for more care must be predictable and finite).

This can also mean you need skilled therapy services. Skilled therapy services can be physical, speech or occupational therapy. If you only need occupational therapy, you will not qualify for the Medicare home health benefit. However, if you qualify for Medicare coverage of home health care on another basis, you can also get occupational therapy. Even when your other needs for Medicare home health end, you should still be able to get occupational therapy under the Medicare home health benefit if you continue to need it.3.

Your doctor signs a home health certification stating that you qualify for Medicare home care because you are homebound and need intermittent skilled care. The certification must also say that a plan of care has been made for you, and that a doctor regularly reviews it. Usually, the certification and plan of care are combined in one form that is signed by your doctor and submitted to Medicare.

As part of the certification, doctors must also confirm that they (or certain other providers, such as nurse practitioners) have had a face-to-face meeting with you related to the main reason you need home care within 90 days of starting to receive home health care or within 30 days after you have already started receiving home health care.

Your doctor must specifically state that the face-to-face meeting confirmed that you are homebound and qualify for intermittent skilled care.

The face-to-face encounter can also be done through a video connection. In certain areas, Medicare will cover examinations done for you in specific places (doctors’ offices, hospitals, health clinics, skilled nursing facilities) through the use of telecommunications (such as video conferencing).4. You receive your care from a Medicare-certified home health agency (HHA). If you qualify for the home health benefit, Medicare covers the following types of care:

Skilled nursing services and home health services provided up to seven days a week for no more than eight hours per day and 28 hours per week. Medicare can cover up to 35 hours in unusual cases, which is probably what you were referring to in your question.

Medicare pays in full for skilled nursing care, which includes services and care that can only be performed safely and effectively by a licensed nurse.

Injections (and teaching patients to self-inject), tube feedings, catheter changes, observation and assessment of a patient’s condition, management and evaluation of a patient’s care plan, and wound care are examples of skilled nursing care that Medicare may cover. Medicare pays in full for a home health aide if you require skilled services. A home health aide provides personal care services including help with bathing, using the toilet, and dressing.

(However, if you only require personal care, you do not qualify for the Medicare home care benefit. )Skilled therapy services. Physical, speech and occupational therapy services that can only be performed safely by or under the supervision of a licensed therapist, and that are reasonable and necessary for treating your illness or injury.

Physical therapy includes gait training and supervision of and training for exercises to regain movement and strength to a body area. Speech-language pathology services include exercises to regain and strengthen speech and language skills. Occupational therapy helps you regain the ability to do usual daily activities by yourself, such as eating and putting on clothes.

Medicare should pay for therapy services to maintain your condition and prevent you from getting worse as long as these services require the skill or supervision of a licensed therapist, regardless of your potential to improve. Medical social services. Medicare pays in full for services ordered by your doctor to help you with social and emotional concerns you have related to your illness.

This might include counseling or help finding resources in your community. Medical supplies. Medicare pays in full for certain medical supplies provided by the Medicare-certified home health agency, such as wound dressings and catheters needed for your care

. Durable medical equipment. Medicare pays 80 percent of its approved amount for certain pieces of medical equipment, such as a wheelchair or walker. You pay 20 percent coinsurance, and could pay up to 15 percent if your home care provider does not accept Medicare’s approved fees.

Aetna considers ankle orthoses, ankle-foot orthoses (AFOs), and knee-ankle-foot orthoses (KAFOs) medically necessary durable medical equipment (DME) according to the criteria set forth below. (See background section of this clinical policy bulletin (CPB) for descriptions of the orthotics discussed in this policy).

Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs)

"Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs)Print Share Number: 0565Policy

Ankle Orthotics Aetna considers ankle orthoses medically necessary DME for members who meet the criteria set forth below. (See background section of CPB for descriptions of each of these orthotics). Ankle air-stirrups: Ankle air-stirrups (e.g., Air Cast) are considered medically necessary DME when used after an ankle injury (fractures or sprains). Air-stirrups are considered experimental and investigational for chronically unstable ankles or to prevent ankle re-injury because of a lack of adequate evidence of the effectiveness of ankle air-stirrups for these indications.

See CPB 0009 - Orthopedic Casts, Braces, and Splints. Elastic ankle sleeves: Aetna considers reusable elastic ankle sleeves medically necessary DME for use to treat an ankle injury (acute and rehabilitative stages). Use of elastic ankle sleeves in a chronically unstable ankle or to prevent ankle re-injury is considered experimental and investigational because of a lack of adequate evidence of the effectiveness of elastic ankle sleeves for these indications.

Lace-up ankle braces: Lace-up ankle braces are considered medically necessary DME when used in members with ankle injuries, when used in members with chronically unstable ankles, or when used to prevent ankle re-injury. Orthopedic ankle cast-braces: Orthopedic ankle cast-braces are considered medically necessary DME when used after an ankle injury (fractures or sprains). See CPB 0009 - Orthopedic Casts, Braces, and Splints. Orthoplast ankle stirrups: Orthoplast ankle stirrups are considered medically necessary DME for use after an acute injury. Use of orthoplast ankle stirrups in chronically unstable ankles or to prevent ankle re-injury is considered experimental and investigational because of a lack of adequate evidence of the effectiveness of orthoplast ankle stirrups for these indications.

Post-operative rehabilitative ankle braces: Aetna considers post-operative rehabilitation ankle braces medically necessary when applied within 6 weeks of surgery.

Such post-operative rehabilitative braces are considered an integral part of surgery. See also CPB 0009 - Orthopedic Casts, Braces, and Splints. Rigid ankle casts: Rigid ankle casts are considered medically necessary DME when used to treat ankle fractures. Rigid ankle casts are considered experimental and investigational when used after ankle sprains, for chronically unstable ankles, or when used to prevent re-injury because of a lack of adequate evidence of the effectiveness of rigid ankle casts for these indications.

Semi-rigid ankle casts: Semi-rigid ankle casts are considered medically necessary DME when used to treat ankle sprains.

Semi-rigid ankle casts are considered experimental and investigational when used after ankle fractures, for use in chronically unstable ankles, or when used to prevent re-injury because of a lack of adequate evidence of effectiveness of semi-rigid ankle cases for these indications. Stabilizing shoes: Stabilizing shoes for ankle injuries (acute or chronic) are considered experimental and investigational.

Note: In addition, most plans contractually exclude foot orthotics. Please check benefit plan descriptions. See CPB 0451 - Foot Orthotics. Unna boots: Unna boots are considered medically necessary DME when used after ankle sprains and other soft tissue injuries. Unna boots are considered experimental and investigational when used after ankle fractures, or when used in chronically unstable ankles or to prevent re-injury because of a lack of adequate evidence of the effectiveness of Unna boots for these indications.

See CPB 0009 - Orthopedic Casts, Braces, and Splints. Ankle Foot Orthoses (AFOs) and Knee Ankle Foot Orthoses (KAFOs)AFOs and KAFOs used in non-ambulatory persons: Static or dynamic positioning ankle foot orthoses (ankle contracture splints) and foot drop splints Static or dynamic positioning ankle foot orthoses: Aetna considers static or dynamic positioning ankle-foot orthoses medically necessary DME if all of the following criteria are met: The static or dynamic positioning ankle-foot orthoses is used as a component of a therapy program that includes active stretching of the involved muscles and/or tendons, and The contracture is interfering or expected to interfere significantly with the member's functional abilities, and There is a reasonable expectation of the ability to correct the contracture, and The member has a plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a non-fixed contracture).

If a static or dynamic positioning ankle-foot orthosis is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home).

A static or dynamic positioning ankle-foot orthosis is considered medically necessary for plantar fasciitis. If a static or dynamic positioning ankle-foot orthosis is considered medically necessary, a replacement interface is also considered medically necessary DME as long as the member continues to meet medical necessity criteria for the splint.

Up to 1 replacement interface per 6 months is considered medically necessary. A static or dynamic positioning ankle-foot orthosis and replacement interface is not considered medically necessary for the following indications: Fixed contractures;Members with foot drop but without an ankle flexion contracture.

Note: In addition, under HMO plans, a static or dynamic positioning ankle-foot orthosis and replacement interface is not considered medically necessary when it is used solely for the prevention or treatment of a heel pressure ulcer because Medicare does not consider it medically necessary for these indications.

A component of a static or dynamic positioning ankle-foot orthosis that is used to address positioning of the knee or hip is considered experimental and investigational because the effectiveness of this type of component is not established. Foot drop splint/recumbent positioning device: Aetna's HMO plans do not consider a foot drop splint/recumbent positioning device or replacement interface medically necessary.

A foot drop splint/recumbent positioning device and replacement interface is not considered medically necessary under HMO plans when it is used solely for the prevention or treatment of a heel pressure ulcer because Medicare does not consider it medically necessary for these indications.

A foot drop splint/recumbent positioning device and replacement interface is not considered medically necessary for members with foot drop who are non-ambulatory because there are other more appropriate treatment modalities.

Additions to AFOs and KAFOs: Additions to AFOs or KAFOs are not considered medically necessary if either the base orthosis is not medically necessary or the specific addition is not medically necessary. AFOs and KAFOs used in ambulatory persons AFOs in ambulatory members: Ankle-foot orthoses (AFO) are considered medically necessary DME for ambulatory members with weakness or deformity of the foot and ankle, which require stabilization for medical reasons, and have the potential to benefit functionally. Members prescribed custom-made “molded-to-patient-model” AFOs must also meet the criteria set forth in section II.

B.3, below. AFOs are not considered medically necessary for ambulatory members who do not meet these medical necessity criteria. Aetna's HMO plans do not consider AFOs and any related addition medically necessary when used solely for the treatment of edema and/or for the prevention or treatment of a heel pressure ulcer in ambulatory patients, as Medicare does not consider AFO's medically necessary for these indications.

Additions to AFOs or KAFOs are not considered medically necessary if either the base orthosis is not medically necessary or the specific addition is not medically necessary. ( Note: Customized Noodle TA AFO and the PHAT dynamic carbon fiber AFO are considered non-covered deluxe items).

KAFOs in ambulatory members: Knee-ankle-foot orthoses (KAFO) are considered medically necessary DME for ambulatory members for whom an ankle-foot orthosis is considered medically necessary and for whom additional knee stability is required. Members prescribed custom-made “molded-to-patient model” KAFOs must also meet the criteria set forth in section II. B.3, below. KAFOs are not medically necessary and are not covered for ambulatory members who do not meet these coverage criteria.

Aetna's HMO plans do not consider KAFOs and any related addition medically necessary when used solely for the treatment of edema and/or for the prevention or treatment of a heel pressure ulcer in ambulatory members, as Medicare does not consider KAFO's medically necessary for these indications.

Molded-to-patient model AFO's and KAFO's in ambulatory members: Custom-made AFOs and KAFOs that are “molded-to-patient-model” are considered medically necessary DME for ambulatory members when the basic medical necessity criteria listed in sections II.

B.1 and II. B.2 above are met and one of the following criteria is met: The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or There is a need to control the knee, ankle or foot in more than 1 plane; or The member could not be fitted with a pre-fabricated (off-the-shelf) AFO; or The member has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or The member has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.

Additions to AFOs and KAFOs: Additions to AFOs and KAFOs are not considered medically necessary if either the base orthosis is not medically necessary and/or the specific addition is not medically necessary.

Concentric adjustable torsion-style mechanisms: Concentric adjustable torsion style mechanisms used to assist knee joint extension are considered medically necessary for members who require knee extension assist in the absence of any co-existing joint contracture.

Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are considered medically necessary for members who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture. A dynamic adjustable ankle extension/flexion device is considered medically necessary for treatment of contractures. Microprocessor-controlled KAFOs: Electronic KAFOs (e.g., the Sensor Walk Electronic KAFO, C-Brace Orthotronic Mobility System) are considered experimental and investigational because of insufficient evidence that they improve ambulation compared to standard KAFOs.

General Notes: Prophylactic orthotics: Aetna does not consider ankle orthotics, AFOs, and KAFOs medically necessary treatment of disease when used to prevent injury in a previously uninjured ankle or knee. Such use is solely preventive, and therefore is considered not considered medically necessary treatment of disease or injury.

In addition, many Aetna plans exclude coverage of safety items. See CPB 0623 - Safety Items. Repairs and replacements: Repairs to a medically necessary ankle orthosis, AFO, or KAFO due to wear and tear are considered medically necessary DME when they are needed to make the orthosis functional.

Replacement of a complete ankle orthosis, AFO, or KAFO or component of these orthoses due to a significant change in the member's condition or irreparable wear is considered medically necessary DME if the device is still medically necessary.

Shoes: Please see CPB 0451 - Foot Orthotics for medical necessity criteria for shoes and related items that are an integral part of a leg brace.

Socks: Socks used in conjunction with ankle orthoses, AFOs, or KAFOs are not covered because socks do not meet the contractual definition of durability for covered DME. Spare orthotics: Identical spare orthotics purchased for the member's convenience is not considered medically necessary.

"Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs)Print Share Number: 0565Policy

Aetna considers ankle orthoses, ankle-foot orthoses (AFOs), and knee-ankle-foot orthoses (KAFOs) medically necessary durable medical equipment (DME) according to the criteria set forth below. (See background section of this clinical policy bulletin (CPB) for descriptions of the orthotics discussed in this policy).

Ankle Orthotics Aetna considers ankle orthoses medically necessary DME for members who meet the criteria set forth below. (See background section of CPB for descriptions of each of these orthotics). Ankle air-stirrups: Ankle air-stirrups (e.g., Air Cast) are considered medically necessary DME when used after an ankle injury (fractures or sprains). Air-stirrups are considered experimental and investigational for chronically unstable ankles or to prevent ankle re-injury because of a lack of adequate evidence of the effectiveness of ankle air-stirrups for these indications.

See CPB 0009 - Orthopedic Casts, Braces, and Splints. Elastic ankle sleeves: Aetna considers reusable elastic ankle sleeves medically necessary DME for use to treat an ankle injury (acute and rehabilitative stages). Use of elastic ankle sleeves in a chronically unstable ankle or to prevent ankle re-injury is considered experimental and investigational because of a lack of adequate evidence of the effectiveness of elastic ankle sleeves for these indications.

Lace-up ankle braces: Lace-up ankle braces are considered medically necessary DME when used in members with ankle injuries, when used in members with chronically unstable ankles, or when used to prevent ankle re-injury. Orthopedic ankle cast-braces: Orthopedic ankle cast-braces are considered medically necessary DME when used after an ankle injury (fractures or sprains). See CPB 0009 - Orthopedic Casts, Braces, and Splints. Orthoplast ankle stirrups: Orthoplast ankle stirrups are considered medically necessary DME for use after an acute injury. Use of orthoplast ankle stirrups in chronically unstable ankles or to prevent ankle re-injury is considered experimental and investigational because of a lack of adequate evidence of the effectiveness of orthoplast ankle stirrups for these indications.

Post-operative rehabilitative ankle braces: Aetna considers post-operative rehabilitation ankle braces medically necessary when applied within 6 weeks of surgery.

Such post-operative rehabilitative braces are considered an integral part of surgery. See also CPB 0009 - Orthopedic Casts, Braces, and Splints. Rigid ankle casts: Rigid ankle casts are considered medically necessary DME when used to treat ankle fractures. Rigid ankle casts are considered experimental and investigational when used after ankle sprains, for chronically unstable ankles, or when used to prevent re-injury because of a lack of adequate evidence of the effectiveness of rigid ankle casts for these indications.

Semi-rigid ankle casts: Semi-rigid ankle casts are considered medically necessary DME when used to treat ankle sprains.

Semi-rigid ankle casts are considered experimental and investigational when used after ankle fractures, for use in chronically unstable ankles, or when used to prevent re-injury because of a lack of adequate evidence of effectiveness of semi-rigid ankle cases for these indications. Stabilizing shoes: Stabilizing shoes for ankle injuries (acute or chronic) are considered experimental and investigational.

Note: In addition, most plans contractually exclude foot orthotics. Please check benefit plan descriptions. See CPB 0451 - Foot Orthotics. Unna boots: Unna boots are considered medically necessary DME when used after ankle sprains and other soft tissue injuries. Unna boots are considered experimental and investigational when used after ankle fractures, or when used in chronically unstable ankles or to prevent re-injury because of a lack of adequate evidence of the effectiveness of Unna boots for these indications.

If a static or dynamic positioning ankle-foot orthosis is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home).

A static or dynamic positioning ankle-foot orthosis is considered medically necessary for plantar fasciitis. If a static or dynamic positioning ankle-foot orthosis is considered medically necessary, a replacement interface is also considered medically necessary DME as long as the member continues to meet medical necessity criteria for the splint.

Up to 1 replacement interface per 6 months is considered medically necessary. A static or dynamic positioning ankle-foot orthosis and replacement interface is not considered medically necessary for the following indications: Fixed contractures;Members with foot drop but without an ankle flexion contracture.

Note: In addition, under HMO plans, a static or dynamic positioning ankle-foot orthosis and replacement interface is not considered medically necessary when it is used solely for the prevention or treatment of a heel pressure ulcer because Medicare does not consider it medically necessary for these indications.

A component of a static or dynamic positioning ankle-foot orthosis that is used to address positioning of the knee or hip is considered experimental and investigational because the effectiveness of this type of component is not established. Foot drop splint/recumbent positioning device: Aetna's HMO plans do not consider a foot drop splint/recumbent positioning device or replacement interface medically necessary.

A foot drop splint/recumbent positioning device and replacement interface is not considered medically necessary under HMO plans when it is used solely for the prevention or treatment of a heel pressure ulcer because Medicare does not consider it medically necessary for these indications.

A foot drop splint/recumbent positioning device and replacement interface is not considered medically necessary for members with foot drop who are non-ambulatory because there are other more appropriate treatment modalities.

Additions to AFOs and KAFOs: Additions to AFOs or KAFOs are not considered medically necessary if either the base orthosis is not medically necessary or the specific addition is not medically necessary. AFOs and KAFOs used in ambulatory persons AFOs in ambulatory members: Ankle-foot orthoses (AFO) are considered medically necessary DME for ambulatory members with weakness or deformity of the foot and ankle, which require stabilization for medical reasons, and have the potential to benefit functionally. Members prescribed custom-made “molded-to-patient-model” AFOs must also meet the criteria set forth in section II.

B.3, below. AFOs are not considered medically necessary for ambulatory members who do not meet these medical necessity criteria. Aetna's HMO plans do not consider AFOs and any related addition medically necessary when used solely for the treatment of edema and/or for the prevention or treatment of a heel pressure ulcer in ambulatory patients, as Medicare does not consider AFO's medically necessary for these indications.

Additions to AFOs or KAFOs are not considered medically necessary if either the base orthosis is not medically necessary or the specific addition is not medically necessary. ( Note: Customized Noodle TA AFO and the PHAT dynamic carbon fiber AFO are considered non-covered deluxe items).

KAFOs in ambulatory members: Knee-ankle-foot orthoses (KAFO) are considered medically necessary DME for ambulatory members for whom an ankle-foot orthosis is considered medically necessary and for whom additional knee stability is required. Members prescribed custom-made “molded-to-patient model” KAFOs must also meet the criteria set forth in section II. B.3, below. KAFOs are not medically necessary and are not covered for ambulatory members who do not meet these coverage criteria.

Aetna's HMO plans do not consider KAFOs and any related addition medically necessary when used solely for the treatment of edema and/or for the prevention or treatment of a heel pressure ulcer in ambulatory members, as Medicare does not consider KAFO's medically necessary for these indications.

Molded-to-patient model AFO's and KAFO's in ambulatory members: Custom-made AFOs and KAFOs that are “molded-to-patient-model” are considered medically necessary DME for ambulatory members when the basic medical necessity criteria listed in sections II.

B.1 and II. B.2 above are met and one of the following criteria is met: The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or There is a need to control the knee, ankle or foot in more than 1 plane; or The member could not be fitted with a pre-fabricated (off-the-shelf) AFO; or The member has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or The member has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.

Additions to AFOs and KAFOs: Additions to AFOs and KAFOs are not considered medically necessary if either the base orthosis is not medically necessary and/or the specific addition is not medically necessary.

Concentric adjustable torsion-style mechanisms: Concentric adjustable torsion style mechanisms used to assist knee joint extension are considered medically necessary for members who require knee extension assist in the absence of any co-existing joint contracture.

Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are considered medically necessary for members who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture. A dynamic adjustable ankle extension/flexion device is considered medically necessary for treatment of contractures. Microprocessor-controlled KAFOs: Electronic KAFOs (e.g., the Sensor Walk Electronic KAFO, C-Brace Orthotronic Mobility System) are considered experimental and investigational because of insufficient evidence that they improve ambulation compared to standard KAFOs.

General Notes: Prophylactic orthotics: Aetna does not consider ankle orthotics, AFOs, and KAFOs medically necessary treatment of disease when used to prevent injury in a previously uninjured ankle or knee. Such use is solely preventive, and therefore is considered not considered medically necessary treatment of disease or injury.

In addition, many Aetna plans exclude coverage of safety items. See CPB 0623 - Safety Items. Repairs and replacements: Repairs to a medically necessary ankle orthosis, AFO, or KAFO due to wear and tear are considered medically necessary DME when they are needed to make the orthosis functional.

Replacement of a complete ankle orthosis, AFO, or KAFO or component of these orthoses due to a significant change in the member's condition or irreparable wear is considered medically necessary DME if the device is still medically necessary.

Shoes: Please see CPB 0451 - Foot Orthotics for medical necessity criteria for shoes and related items that are an integral part of a leg brace.

Socks: Socks used in conjunction with ankle orthoses, AFOs, or KAFOs are not covered because socks do not meet the contractual definition of durability for covered DME. Spare orthotics: Identical spare orthotics purchased for the member's convenience is not considered medically necessary.

ed. Your costs in Original Medicare If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways.

Your Medicare Coverage

Is my test, item, or service covered? Go Blood sugar (glucose) monitors How often is it covered?

Medicare Part B (Medical Insurance) covers blood sugar monitors as durable medical equipment (DME) that your doctor prescribes for use in your home.

Who's eligible? All people with Part B are cover

Suppliers / Durable Medical Equipment & Medical Supplies is the primary health care specialty. Apria Healthcare Inc can be contacted via phone (325) 677-2405, or through Starck, Daniel via phone (949) 639-2000 . Suppliers / Durable Medical Equipment & Medical Supplies A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient’s use in the home and that are usable for an extended period of time.

Apria Healthcare Inc

share on Apria Healthcare Inc LBN: Apria Healthcare Inc Apria Healthcare Inc is an health care organization with primary practice located at 3250 S Treadaway Blvd , Abilene TX 79602-6734.

The organization recently has 3 registered licenses in different health care specialties including Suppliers / Durable Medical Equipment & Medical Supplies, Suppliers / Parenteral & Enteral Nutrition, Suppliers / Oxygen Equipment & Supplies.

Contact Information Primary practice address3250 S Treadaway Blvd Abilene TX 79602-6734Phone: (325) 677-2405Fax: Website: Map and Directions Authorized official contact: Name: Starck, Daniel Phone: (949) 639-2000Health care specialties Specialty Code License # State Suppliers / Durable Medical Equipment & Medical Supplies332B00000XSuppliers / Parenteral & Enteral Nutrition332BP3500XSuppliers / Oxygen Equipment & Supplies332BX2000XProfile Details NPI number1235443532LBN Legal business name Apria Healthcare Inc DBA Doing business as Authorized official Starck, Daniel Entity Organization Organization subpart 1 Yes Enumeration date Jul 29th, 2010Last updated Jan 22nd, 2013 - about 5 years ago1Some organizations, which are providing health care services, may consist of units or departments that provide different types of health care services or have several separate physical locations, where health care service is provided.

These units, departments or physical locations are not themselves legal entities. However, each of them is part of the organization, which is a legal entity.

The organization may decide whether its subparts, if it has any, should have their own NPI numbers. In case a subpart conducts any HIPAA standard transactions by itself, without its parent's involvement, it must have its own NPI number. Request for update

They are small enough to fit in a car and most of the major concentrators are now FAA approved. Whether you need a ventilator, CPAP machine, oxygen concentrator, or other type of respiratory aid, you can find it from local durable healthcare equipment suppliers and national medical equipment distribution companies.

Rent Oxygen Concentrator , CPAP Machine Rental, POC Rentals

Rent Oxygen Concentrator , CPAP Machine Rental, POC Rentals Oxygen Tanksfor Rent | Respiratory Equipment | Portable Oxygen Concentrators Rentals Since 2000, a number of manufacturers have introduced portable oxygen concentrators that can be used as a travel system.

It is very similar to a home oxygen concentrator, but it is smaller in size and more mobile. The portable oxygen concentrator makes it easy for patients to travel freely.

Medical Respiratory Equipment Rentals An oxygen concentrator is a device used to provide oxygen therapy to a patient at substantially higher concentrations than available in ambient air. They are used as a safer, less expensive, and more convenient alternative to tanks of compressed oxygen.

Typically, patients use this medical device in the treatment of emphysema and other respiratory system diseases. It is also used as an adjunct to CPAP, or continuous positive airway pressure, and for treatment of severe sleep apnea. It is also used in the treatment of chronic obstructive pulmonary disease, or COPD. This is persistent obstruction of the airways occurring with emphysema, chronic bronchitis, or both disorders. In the United States, about 12 million people suffer COPD. COPD leads to chronic airflow obstruction, which is defined as a persistent decrease in the rate of airflow from the lungs when the person breathes out (exhales).

This airflow obstruction is partially reversible in some people, either spontaneously or with treatment. Different devices are available for COPD oxygen therapy. Electrically driven oxygen concentrators are used when electrical outlets are available.

Compressed oxygen is available in small tanks that permit people to travel outside of their homes for 2 to 6 hours. Oxygen Concentrator Rental & Portable Oxygen Concentrators Oxygen Concentrator Rentals: The purpose of an oxygen concentrator is to deliver continuous oxygen to patients.

It has two cylinders, each filled with a zeolite material which selectively absorbs the nitrogen in the air. In each cycle, air flows through one cylinder at a pressure of around 20 psig, where psig indicates the gauge pressure (138 k Pa, or 1.36 atmospheres) where the nitrogen molecules are captured by the zeolite, while the other cylinder is vented off to ambient atmospheric pressure allowing the captured nitrogen to dissipate.

Typical units have cycles of around 20 seconds, and allow for a continuous supply of oxygen at a flow rate of up to approximately five liters per minute (LPM) at concentrations anywhere from 50 to 95 %. This process is called pressure swing absorption (PSA). Since 1999, concentrators providing up to 10 LPM have been available for high flow patients, in sizes not much larger or heavier than 5 LPM concentrators.

CPAP Breathing Machine Rentals CPAP system rentals are commonly used for sleep apnea and to help people get the proper rest needed to stay healthy. CPAP or Continuous Positive Airway Pressure therapy is a method of respiratory ventilation. It uses a CPAP machine to increase air pressure in your throat so that your airway doesn’t collapse when you inhale.

It is commonly used to treat sleep apnea and can be used every night while sleeping. It can also be used in the treatment of various illnesses requiring respiratory ventilation. If your doctor has recommended the use of a BIPAP machine you can view our BIPAP system rentals. Nebulizer Systems For Rent Nebulizer Rentals: A nebulizer is a machine that turns liquid medication into a mist so that it can be inhaled directly into the lungs through a face mask or a mouthpiece.

Oxygen, compressed air or ultrasonic power is used to turn the medication into a breathable mist . Cystic fibrosis, asthma, chronic obstructive pulmonary disease, or COPD, and other respiratory diseases use nebulizers rentals for treatment. Featured Oxygen Concentrator Rentals New Oxygen Concentrator Rentals Featured Oxygen Concentrator Rentals - Rent It Today An oxygen concentrator is a device used to provide oxygen therapy to a patient at substantially higher concentrations than available in ambient air. They are used as a safer, less expensive, and more convenient alternative to tanks of compressed oxygen. Renting Oxygen Concentrators Has Never Been This Simple!

are Patients with questions about Medicare and DME coverage may call 800-633-4227 for clarification (877-486-2048 for TTY [hearing impaired] users). 1 For covered equipment, the patient generally pays 20% of the Medicare-approved amount after meeting the 2008 deductible of $135.

Durable Medical Equipment: A Challenging Practice

"Published June 19, 2008otc medications Durable Medical Equipment: A Challenging Practice W. Steven Pray, Ph D, DPh Bernhardt Professor of Nonprescription Drugs and Devices College of Pharmacy Southwestern Oklahoma State University Weatherford, Oklahoma US Pharm. 2008;33 (6):10-15. Providing durable medical equipment (DME) can develop into a lucrative and rewarding aspect of a pharmacy's total patient care role.

Pharmacies deciding to supply DME should explore the benefits of enrollment in Medicare, which is administered by the Centers for Medicare & Medicaid Services (CMS), working in conjunction with other contractors.

1 Legislation determines program requirements, and various regulations and directives clarify the details. Medicare Part B is the section that concerns DME. While not mandatory, pharmacy enrollment will enable Medicare-covered patients to realize the full benefits of their coverage.

Should a Medicare patient purchase or rent DME from a pharmacy not enrolled in Medicare, the government program will not pay the claim.

2Becoming a DME Supplier A pharmacy wishing to become a DME supplier to Medicare patients must first apply by completing Form CMS-855S (www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf) for all prospective suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). 3 After the form with supporting documentation is submitted, it will be processed by the National Supplier Clearinghouse (NSC) to verify all information.

A site visit will be scheduled to verify compliance with DMEPOS Supplier Standards, as set forth in 42 CFR 424.57 (http://edocket.access.gpo.gov/cfr_2002/octqtr/pdf/42cfr424.57.pdf). Accepting Assignment Pharmacies may ease the burden on their patients by accepting assignment. Assignment is an agreement between the pharmacy and the patient that it will accept the Medicare-approved amount as full payment. After the patient has paid the part B deductible ($135 for 2008), the pharmacy accepting assignment can only collect the coinsurance (usually 20% of the approved amount).

1 Pharmacies that make this decision are known as participating suppliers. If the pharmacy is enrolled in Medicare but chooses not to be a participating supplier, it has the option of whether or not to accept assignment. In theory, there is no limit to the amount that pharmacies can charge when they refuse to accept assignment. For this reason, it is incumbent on the nonparticipating pharmacy to make all costs clear in the form of a contract. DME Covered by Medic

Medicare-covered DME includes air-fluidized beds, blood glucose monitors, osteogenesis stimulators (a Certificate of Medical Necessity [CMN] is required), canes, commode chairs, crutches, home oxygen equipment and supplies (CMN required), hospital beds, infusion pumps, nebulizers, scooters, suction pumps, traction equipment, transcutaneous electronic nerve stimulators (CMN required), walkers, wheelchairs, braces, breast prostheses, and ostomy supplies.

1Do Chronically Disabled Elderly Underuse DME? Pharmacies can be more aggressive in promoting the use of DME to patients with severe disability. A severe disability is one that requires an assistive device or presents trouble with at least one activity of daily living.

4 As many as 30% to 54% of those over 65 years have such a disability. 4 An estimated 75% to 90% of disabled elderly living in the community require some type of assistive technology.

5 Wheelchairs and braces are required by 1.5 million elderly patients not living in institutions. 4Researchers examined a group of 4,687 noninstitutionalized elderly Medicare enrollees (average age of 75.6 years). 4 Many met the given definitions of disability, yet very few made use of their DME benefit under Medicare. This finding held true for the chronically disabled and for those with a disability of recent onset.

This finding is borne out by the fact that over half of patients aged 65 and above who require assistive devices spend their own funds to obtain them. 5The Controversy Over Power Mobility Devices Medicare has long been the target of fraud and theft.

Pharmacies contemplating entry into the DME market must protect themselves against any hint of fraudulent activity. The official booklet from CMS contains an interesting statement: ""Most suppliers who work with Medicare are honest. There are a few who aren't honest. Medicare is working with other government agencies to protect you and the Medicare Program from dishonest suppliers of power wheelchairs and scooters.""

1 This brief statement is a distillation of a major controversy surrounding the use of two types of power mobility devices (PMDs): power wheelchairs and power-operated vehicles. 6The Department of Justice (DOJ) discussed a 2007 settlement with a leading PMD supplier that promised in its advertisements to give applicants a power chair or scooter ""absolutely free"" if they completed the company's program.

7,8 The DOJ alleged that the company violated the civil False Claims Act and defrauded the United States. Allegedly, the company engaged in an attractive multimedia campaign that enticed consumers to obtain power scooters paid for by Medicare, Medicaid, and other insurers. 8 However, the consumer did not receive the ""zippy"" power scooters that were the focus of the advertisements.

Instead, the company sold beneficiaries expensive power wheelchairs. The recipients did not want those devices, did not need them, and/or could not use them. The company allegedly accomplished this by representing to physicians that the patients desired and needed power wheelchairs.

The duped physicians filled out thousands of CMN forms, not knowing that they were doing so by means of fraudulent practices. The company allegedly billed government and private health care insurers for the power wheelchairs and fraudulently collected millions of Medicaid/ Medicare dollars, since the devices are far more costly than power scooters.

Power wheelchairs are reimbursed at a rate of $5,000 to $7,000, while power scooters are only reimbursed at $1,500 to $2,000. In addition, many patients were not told about the switch until they received the equipment and discovered it to be far removed from what they had envisioned.

8The DOJ also alleged that the company billed Medicare for new equipment but actually sold used devices, and that it charged Medicare millions of dollars for unnecessary power mobility accessories. The company agreed to settle the allegations by paying $4 million to the U. S. and also by giving up $13 to $43 million dollars in pending claims.

8 A whistleblower, who was a former employee, received over $3 million of the settlement as a statutory award. The Assistant Attorney General stated, ""Equipment suppliers whose practices violate the law need to know that we are dedicated to protecting Medicare funds and beneficiaries from their fraudulent schemes.""

There have been many other instances. 9-11New Competitive Bidding Program On May 1, 2006, CMS published a proposed rule in the Federal Register to alter the method by which Medicare pays pharmacies and other suppliers by implementing a competitive bidding process for certain covered items of DMEPOS.

12 The purpose was stated as: ""Competitive bidding provides a way to harness marketplace dynamics to create incentives for suppliers to provide quality items in an efficient manner and at reasonable cost to the program.""

CMS hoped that the new program might ""reduce the amount Medicare pays for DMEPOS and create a payment structure under competitive bidding that is more reflective of a competitive market."" 13 CMS explained its intention to phase in competitive bidding gradually, perhaps first including those products with the greatest potential for savings.

Some of the most expensive items, in decreasing order, were oxygen concentrators, power wheelchairs with programmable features, blood glucose reagent strips (a expense of almost $800 million yearly), semi-electric hospital beds, portable gaseous oxygen equipment, enteral formulas, enteral feeding kits, lancets, and nebulizers. On April 10, 2007, CMS published its Final Rule on the competitive bidding proposal. 13 The agency discussed the 2,129 comments it had received on the proposed rule. Despite many comments disagreeing with certain provisions of the proposed rule, CMS finalized the rule and planned for its implementation.

Beginning July 1, 2008, CMS will implement the new Competitive Bidding Program in specific geographic areas.

The first phase of the program will affect pharmacies and other suppliers in: Charlotte-Gastonia-Concord (North and South Carolina); Cincinnati-Middletown (Ohio, Kentucky, Indiana); Cleveland-Elyria-Mentor (Ohio); Dallas-Fort Worth-Arlington (Texas); Kansas City (Missouri, Kansas); Miami-Fort Lauderdale-Miami Beach (Florida); Orlando (Florida); Pittsburgh (Pennsylvania); Riverside-San Bernardino-Ontario (California); and San Juan-Caguas-Guaynabo (Puerto Rico).

1 Suppliers who are unsure whether their zip code is included in the new Competitive Bidding Program may call 1-800-MEDICARE. Information on the new program is also available at www.medicare.gov. Being Trained in DMEAs can be seen by this discussion, a major consideration in supplying DME is ensuring compliance with Medicare regulations.

There are many other considerations, however. The pharmacists and staff involved in the practice should obtain training to understand the various difficulties involved in DME sales. The manufacturers often have sophisticated educational programs in place. If the pharmacy proposes to enter the ostomy market, for instance, it is recommended that the manufacturers of these products be contacted to ascertain the various educational efforts that are already available.

With appropriate training, this potentially lucrative area can allow the pharmacy DME supplier to assume an enhanced role in the community. REFERENCES1. Medicare Coverage of Durable Medical Equipment and Other Devices. Baltimore, MD: Centers for Medicare & Medicaid Services; 2007.2.

Johnson PE. Changes in reimbursement rates and rules associated with the Medicare Prescription Drug Improvement and Modernization Act. Introduction. Am J Health Syst Pharm. 2006; 63 (suppl 7): S2-S6.3. Medicare Enrollment for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers.

Baltimore, MD: Centers for Medicare & Medicaid Services; 2006.4. Iwashyna TJ, Christie JD. Low use of durable medical equipment by chronically disabled elderly. J Pain Symptom Manage. 2007;33:324-330.5. Wolff JL, Agree EM, Kasper JD. Wheelchairs, walkers, and canes: what does Medicare pay for, and who benefits?

Health Aff. 2005;24:1140-1149.6. Medicare Coverage of Power Mobility Devices (PMDs): Power Wheelchairs and Power Operated Vehicles (POVs). Baltimore, MD: Centers for Medicare & Medicaid Services; 2007.7. The Scooter Store guaranteed freedom program.

www.thescooterstore.com/mobility/spur/ppc/14/defaultb.aspx. Accessed April 23, 2008.8. The Scooter Store to pay United States $4 million to resolve False Claims Act allegations. Department of Justice. May 11, 2007. www.usdoj.gov/opa/pr/2007/May/07_civ_344.html. Accessed April 23, 2008.9. Doctors, others indicted for Medicare fraud, money laundering. Office of the U. S. Attorney-Western District of Missouri.

January 4, 2006. www.usdoj.gov/usao/mow/news2006/igbokwe.ind.pdf. Accessed April 23, 2008.10. Houston man investigated by Medicaid Fraud Control Unit receives 15 years in prison for theft. Attorney General of Texas. December 6, 2007. www.oag.state.tx.us/oagnews/release.php?id=2293. Accessed April 23, 2008.11. Nigerian national sentenced for Medicare fraud. Office of the U. S. Attorney-Western District of Missouri. February 21, 2007. http://kansascity.fbi.gov/dojpressrel/pressrel07/medicarefraud022107.htm. Accessed April 23, 2008.12. Medicare program; competitive acquisition for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and other issues. Proposed rule. Fed Reg . 2006;71:25654-25704.13. Medicare program; competitive acquisition for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and other issues. Final rule. Fed Reg. 2007;72:17992-18090.14. Lowes R. Need equipment? Think e Bay. Med Econ. 2005;82:27-28. To comment on this article, contact rdavidson@jobson.com . Read More On: OTC MEDICATIONS "

Aetna considers full-leg or half-leg pneumatic compression devices for home use medically necessary durable medical equipment (DME) for the treatment of chronic venous insufficiency of the legs of members who have venous stasis ulcers that have failed to heal after a 6-month trial of conservative therapy directed by the treating physician.

Intermittent Pneumatic Compression Devices

"Intermittent Pneumatic Compression Devices Print Share Number: 0500Policy

The trial of conservative therapy must include a compression bandage system or compression garment, appropriate dressings for the wound, exercise, and elevation of the limb. When a pneumatic compression device is determined to be medically necessary, a non-segmented device or segmented device without manual control of the pressure in each chamber is generally considered adequate to meet the clinical needs of the member.

A segmented device with manual control of the pressure in each chamber is considered medically necessary only if there is clear documentation of medical necessity in the individual case.

A segmented device with manual control of the pressure in each chamber is considered medically necessary only when there is documentation that the individual has unique characteristics that prevent satisfactory pneumatic compression treatment using a non-segmented device with a segmented appliance/sleeve or a segmented device without manual control of the pressure in each chamber.

Aetna considers intermittent pneumatic compression devices of the lower extremities medically necessary DME to stimulate circulation and reduce the chances of deep venous thromboses for members who are unable to walk or bedridden due to trauma, orthopedic surgery, neurosurgery or other circumstances preventing ambulation.

Aetna considers intermittent pneumatic compression devices experimental and investigational for the following (not an all-inclusive list) because there is inadequate evidence of their effectiveness for these indications: Enhancement of fracture and soft-tissue healing Management of edema following femoro-popliteal bypass surgery Rehabilitation for distal radial fractures Treatment of critical limb ischemia Treatment of peripheral arterial occlusive disease/arterial insufficiency Treatment of restless legs syndrome Treatment of sensory impairment in the upper limb following stroke Treatment of upper extremity vascular ulcers Aetna considers a single patient use intermittent pneumatic compression device (e.g., the Vena Pro Vascular Therapy System) not medically necessary.

Note: For persons with a medically necessary inflatable compression garment (e.g., Flowtron Compression Garment, Jobst Pneumatic Compressor), a pump needed to inflate the compression garment is considered medically necessary. See also CPB 0069 - Lymphedema for Aetna's policy on pneumatic compression devices for arm lymphedema and CPB 0482 - Compression Garments for the Legs.

Background Gradient elastic stockings, such as those made by Jobst, Sigvaris, Juzzo, or Medi, are generally viewed as the principle means of preventing complications of chronic venous insufficiency. Intermittent pneumatic compression devices compress the leg and/or foot and ankle and act as a pump to improve circulation in the lower extremities. Pneumatic compression devices consist of an inflatable garment for the leg and an electrical pneumatic pump that fills the garment with compressed air.

The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. Intermittent pneumatic compression (IPC) boots are generally accepted as a method for preventing deep venous thromboses (DVT) and complications of venous stasis in persons after trauma, orthopedic surgery, neurosurgery, or who for other reasons are unable to walk.

Use of the IPC device has expanded to ambulatory persons who suffer from chronic venous insufficiency (CVI) of the legs and consequent edema, stasis dermatitis, ulcerations, and cellulitis.

CVI of the legs is caused by abnormalities of the venous wall and valves, leading to obstruction or reflux of blood flow in the veins. A systemic review of the literature concluded that the effectiveness of the addition of IPC in treatment of venous leg ulcers is unknown.

The systemic review identified 3 small, randomized controlled trials (RCTs) of IPC; all of these trials were different in design. Upon pooling of the results, using a random effects model, the reviewers found no difference in healing rates.

The review concluded that “ [t]hree small [randomized controlled trials] found no evidence of a significant effect on healing with intermittent pneumatic compression in conjunction with compression bandages.”There is no evidence that IPC devices are superior to gradient compression stockings in preventing complications of chronic venous disease. Compliance with gradient compression stockings has been shown to be essential to their effectiveness; the stockings do not work unless they are worn.

There are no studies, however, that have demonstrated that compliance with IPC devices is significantly greater than compliance with gradient compression stockings. The A-V Impulse System Foot Pump and the KCI Plexipulse are brands of IPC boots on the market; others include those manufactured by Jobst, Chattanooga, Kendal, and Nutech.

The Canadian Coordinating Office of Health Technology Assessment (2004) concluded that “EPC [external pneumatic compression] reduces the risk of DVT for patients who cannot walk due to trauma, joint surgery or neurosurgery. There is still limited evidence, however, supporting the effect of EPC on the healing of venous ulcers and other disorders resulting from chronic VI [venous insufficiency]”. Current evidence supporting the use of pneumatic compression devices in peripheral arterial disease is limited to small pilot studies with short-term follow up.

In a pilot study (n = 30), Ramaswami et al (2005) examined the usefulness of rapid, high-pressure, intermittent pneumatic calf and foot compression (IPCFC) in patients with stable intermittent claudication. These investigators concluded that “IPCFC improves walking distance in patients with stable intermittent claudication.

The combination of IPCFC with other treatment such as risk-factor modification and daily exercise may prove useful in patients with peripheral arterial occlusive disease. It may be a useful first line of therapy in patients with disabling claudication who are unfit for major reconstructive surgery. Improved walking on long-term follow-up and experience from different centers may establish a role for this treatment modality in the future”.

Kakkos et al (2005) compared the effect of unsupervised exercise, supervised exercise and IPCFC on the claudication distance, lower limb arterial hemodynamics and quality of life of patients with intermittent claudication (n = 34). These researchers concluded that IPCFC achieved improvement in walking distance comparable with supervised exercise.

Long-term results in a larger number of patients will provide valuable information on the optimal treatment modality of intermittent claudication. Khanna et al (2008) stated that current methods of fracture care use various adjuncts to try and decrease time to fracture union, improve fracture union rates and enhance functional recovery; and one such modality is IPC.

These researchers performed a literature review on this approach. A total of 16 studies on the use of IPC in fracture and soft-tissue healing were identified. These studies demonstrated that IPC facilitates both fracture and soft-tissue healing with rapid functional recovery. The authors concluded that IPC appears to be an effective modality to enhance fracture and soft-tissue healing.

Moreover, they noted that the number of subjects in human studies is small, and adequately powered RCTs are needed to produce stronger clinically relevant evidence. In a prospective, randomized, double-blinded, sham-controlled trial, Lettieri and Eliasson (2009) evaluated the effectiveness of pneumatic compression devices (PCDs) as a non-pharmacologic treatment for restless legs syndrome (RLS). Subjects wore a therapeutic or sham device prior to the usual onset of symptoms for a minimum of 1 hour daily.

Measures of severity of illness, quality of life, daytime sleepiness, and fatigue were compared at baseline and after 1 month of therapy.

A total of 35 subjects were enrolled. Groups were similar at baseline. Therapeutic PCDs significantly improved all measured variables more than shams. Restless legs severity score improved from 14.1 +/- 3.9 to 8.4 +/- 3.4 (p = 0.006) and Johns Hopkins restless legs scale improved from 2.2 +/- 0.5 to 1.2 +/- 0.7 (p = 0.01).

All quality of life domains improved more with therapeutic than sham devices (social function 14 % versus 1 %, respectively; p = 0.03; daytime function 21 % versus 6 %, respectively, p = 0.02; sleep quality 16 % versus 8 %, respectively, p = 0.05; emotional well-being 17 % versus 10 %, respectively, p = 0.15).

Both Epworth sleepiness scale (6.5 +/- 4.0 versus 11.3 +/- 3.9, respectively, p = 0.04) and fatigue (4.1 +/- 2.1 versus 6.9 +/- 2.0, respectively, p = 0.01) improved more with therapeutic devices than sham devices.

Complete relief occurred in 1/3 of subjects using therapeutic and in no subjects using sham devices.

The authors concluded that PCDs resulted in clinically significant improvements in symptoms of RLS in comparison to the use of sham devices and may be an effective adjunctive or alternative therapy for RLS. Moreover, the authors stated that before PCD therapy is ready for more wide-spread use, it will be important to see validating studies in various populations of RLS patients.

In a prospective, randomized trial, te Slaa et al (2011) examined the effects of IPC for the treatment and prevention of post-reconstructive edema following femoro-popliteal bypass surgery. Patients were assigned to one of two groups. All patients suffered from peripheral arterial disease, and all were subjected to autologous femoro-popliteal bypass reconstruction.

Patients in group 1 used a compression stocking (CS) above the knee exerting 18 mm Hg (class I) on the leg post-operatively for 1 week (day and night). Patients in group 2 used IPC on the foot post-operatively at night for 1 week. The lower leg circumference was measured pre-operatively and at 5 post-operative time points.

A multi-variate analysis was done using a mixed model analysis of variance. A total of 57 patients were analyzed (n = 28 for CS; n = 29 for IPC). Indications for operation were severe claudication (CS 13; IPC 13), rest pain (10/5), or tissue loss (7/11). Re-vascularization was performed with either a supra-genicular (CS 13; IPC 10) or an infra-genicular (CS 15; IPC 19) autologous bypass.

Leg circumference increased on day 1 (CS/IPC): 0.4 %/2.7 %, day 4 (2.1 %/6.1 %), day 7 (2.5 %/7.9 %), day 14 (4.7 %/7.3 %), and day 90 (1.0 %/3.3 %) from baseline (pre-operative situation).

On days 1, 4, and 7 there was a significant difference in leg circumference between the 2 treatment groups. The authors concluded that edema following femoro-popliteal bypass surgery occurs in all patients. For the prevention and treatment of edema following femoro-popliteal bypass surgery, the use of a class I CS proved superior to treatment with IPC. The authors concluded that the use of CS remains the recommended practice following femoro-popliteal bypass surgery.

Pfizenmaier et al (2005) noted that ischemic vascular ulcerations of the upper extremities are an uncommon and frequently painful condition most often associated with scleroderma and small vessel inflammatory diseases. Digital amputation has been advocated as primary therapy because of the poor outcome with medical care. Intermittent pneumatic compression pump therapy can improve ulcer healing in lower extremity ischemic ulcerations; however, the value of this treatment in upper extremity ischemic ulcerations is not known.

This observational pilot study consisted of a consecutive series of 26 patients with 27 upper extremity ischemic vascular ulcers seen at the Mayo Gonda Vascular Center from 1996 to 2003. Inclusion criteria were documented index of ulcer size and follow-up ulcer size and use of the IPC pump as adjunctive wound treatment.

Twenty-six of 27 ulcers (96 %) healed with the use of the IPC pump. Mean baseline ulcer size was 1.0 cm2 (SD = 0.3 cm2) and scleroderma was the underlying disease in 65 % (17/26) of cases.

Laser Doppler blood flow in the affected digit was 7 flux units (normal greater than 100). The mean ulcer duration before IPC treatment was 31 weeks. The average pump use was 5 hours per day. The mean time to wound healing was 25 weeks. Twenty-five of 26 patients reported an improvement in wound pain with pump use.

The authors concluded that intensive IPC pump use is feasible and associated with a high rate of healing in upper extremity ischemic ulcers.

Furthermore, they stated that prospective, RCTs of IPC is needed to determine whether IPC treatment improves wound healing compared to standard medical care. Handoll et al (2006) examined the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures. These investigators searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, conference proceedings and reference lists of articles.

No language restrictions were applied. Randomized or quasi-RCTs evaluating rehabilitation as part of the management of fractures of the distal radius sustained by adults. Rehabilitation interventions such as active and passive mobilization exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians.

The authors independently selected and reviewed trials. Study authors were contacted for additional information. No data pooling was done. A total of 15 trials, involving 746 mainly female and older patients, were included.

Initial treatment was conservative, involving plaster cast immobilization, in all but 27 participants whose fractures were fixed surgically. Though some trials were well-conducted, others were methodologically compromised. For interventions started during immobilization, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing 1 month later (1 trial). There was weak evidence of improved hand function in the short-term, but not in the longer term (3 months), for early occupational therapy (1 trial), and of a lack of differences in outcome between supervised and unsupervised exercises (1 trial).

For interventions started post-immobilization, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (4 trials), passive mobilization (2 trials), ice or pulsed electromagnetic field (1 trial), or whirlpool immersion (1 trial) compared with no intervention.

There was weak evidence of a short-term benefit of continuous passive motion (post-external fixation) (1 trial), IPC (1 trial) and ultrasound (1 trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (1 trial).

The authors concluded that the available evidence from RCTs is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius. In a preliminary study, Cambier et al (2003) evaluated the effectiveness of IPC in treating sensory impairments in the hemiplegic upper limb in stroke patients.

A total of 23 stroke patients were enrolled in this RCT that compared the application of IPC with a passive treatment strategy. The experimental group (n = 11) received standard physiotherapy combined with IPC treatment (10 cycles of 3 mins with a peak of 40 mm Hg) for their hemiplegic upper limb.

The control group (n = 12) received supplementary to their conventional physiotherapy a placebo treatment, namely sham short-wave therapy on the hemiplegic shoulder for 30 mins.

Sensory impairments were clinically assessed at 3 occasions over a period of 4 weeks using the Nottingham Sensory Assessment scale. Both groups improved in somato-sensation over time, but the experimental group improved more than the control group (p = 0.036) or 81.1% improvement versus 30.9 %. The authors concluded that the use of IPC in the rehabilitation of stroke patients may be of clinical importance for the restoration of sensory function.

Drawbacks of this study included small sample size and short follow-up period. Doyle et al (2010) examined the effects of interventions that target upper limb sensory impairment after stroke. These investigators searched the Cochrane Stroke Group Trials Register (last searched October 8, 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to January 2009), EMBASE (1980 to January 2009), and 6 further electronic databases to January 2009.

They also hand-searched relevant journals, contacted authors in the field, searched doctoral dissertation databases, checked reference lists, and completed citation tracking.

Randomized controlled trials and controlled trials comparing interventions for sensory impairment after stroke with no treatment, conventional treatment, attention placebo or with other interventions for sensory impairment were included in this analysis. Two review authors selected studies, assessed quality and extracted data. They analyzed study data using mean differences and odds ratios as appropriate.

The primary outcome was sensory function; and secondary outcomes included upper limb function, activities of daily living, impact of stroke and quality of life as well as adverse events. These researchers included 13 studies, with a total 467 participants, testing a range of different interventions. Outcome measures included 36 measures of sensory impairment and 13 measures of upper limb function.

All but 2 studies had unclear or high-risk of bias. While there is insufficient evidence to reach conclusions about the effects of interventions included in this review, 3 studies provided preliminary evidence for the effects of some specific interventions, including mirror therapy for improving detection of light touch, pressure and temperature pain; a thermal stimulation intervention for improving rate of recovery of sensation; and IPC intervention for improving tactile and kinesthetic sensation.

These researchers could not perform meta-analysis due to a high-degree of clinical heterogeneity in both interventions and outcomes. The authors concluded that there is insufficient evidence to support or refute the effectiveness of the described interventions in improving sensory impairment, upper limb function, or participants' functional status and participation.

Moreover, they stated that there is a need for more well-designed, better-reported studies of sensory rehabilitation. The American College of Chest Physicians’ evidence-based clinical practice guidelines on “Antithrombotic and thrombolytic therapy for ischemic stroke” (Lansberg et al, 2012) provided recommendations on the use of anti-thrombotic therapy in patients with stroke or transient ischemic attack (TIA).

These investigators generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence. In patients with acute ischemic stroke, these researchers recommended IV recombinant tissue plasminogen activator (r-t PA) if treatment can be initiated within 3 hrs (Grade 1A) or 4.5 hrs (Grade 2C) of symptom onset; these investigators suggested intra-arterial r-t PA in patients ineligible for IV t PA if treatment can be initiated within 6 hrs (Grade 2C); they suggested against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and they recommended early aspirin therapy at a dose of 160 to 325 mg (Grade 1A).

In patients with acute stroke and restricted mobility, the authors suggested the use of prophylactic-dose heparin or IPC devices (Grade 2B) and suggested against the use of elastic compression stockings (Grade 2B). In patients with a history of non-cardioembolic ischemic stroke or TIA, they recommended long-term treatment with aspirin (75 to 100 mg once-daily), clopidogrel (75 mg once-daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no anti-platelet therapy (Grade 1A), oral anti-coagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B).

Of the recommended anti-platelet regimens, the authors suggested clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation, they recommended oral anti-coagulation over no anti-thrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B).

Zhao and colleagues (2012) noted that total hip replacement (THR) is an effective treatment for reducing pain and improving function and quality of life in patients with hip disorders. While this operation is very successful, DVT and pulmonary embolism (PE) are significant complications after THR. Different types of IPC devices have been used for thrombosis prophylaxis in patients following THR.

Available devices differ in compression garments, location of air bladders, patterns of pump pressure cycles, compression profiles, cycle-length, duration of inflation time and deflation time, or cycling mode such as automatic or constant cycling devices.

Despite the widely accepted use of IPC for the treatment of arterial and venous diseases, the relative effectiveness of different types of IPC systems as prophylaxis against thrombosis after THR is still unclear. In a Cochrane review, these investigators evaluated the comparative safety and effectiveness of different IPC devices with respect to the prevention of venous thromboembolism in patients after THR. The Cochrane Peripheral Vascular Diseases Group Trials Search Coordinator searched the Specialized Register (May 2012), CENTRAL (2012, Issue 4), MEDLINE (April Week 3 2012) and EMBASE (Week 17 2012).

Clinical trial databases were searched for details of ongoing and unpublished studies. Reference lists of obtained articles were also screened.

There were no limits imposed on language or publication status. Randomized and quasi-RCTs were eligible for inclusion. Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data.

Disagreement was resolved by discussion or, if necessary, referred to a third review author. Only 1 quasi-RCT with 121 study participants comparing 2 types of IPC devices met the inclusion criteria. The authors found no cases of symptomatic DVT or PE in either the calf-thigh compression group or the plantar compression group during the first 3 weeks after the THR. The calf-thigh pneumatic compression was more effective than plantar compression for reducing thigh swelling during the early post-operative stage.

The strength of the evidence in this review was weak as only 1 trial was included and it was classified as having a high-risk of bias. The authors concluded that there is a lack of evidence from RCTs to make an informed choice of IPC device for preventing venous thromboembolism (VTE) following THR.

They stated that more research is needed, ideally a multi-center, properly designed RCT including a sufficient number of participants. Clinically relevant outcomes such as mortality, imaging-diagnosed asymptomatic VTE and major complications must be considered. Dennis et al (2013) evaluated the effectiveness of IPC to reduce the risk of DVT in patients who have had a stroke.

The CLOTS 3 trial is a multi-center parallel group randomized trial assessing IPC in immobile patients (i.e., who cannot walk to the toilet without the help of another person) with acute stroke. These researchers enrolled patients from day 0 to day 3 of admission and allocated them via a central randomization system (ratio 1:1) to receive either IPC or no IPC. A technician who was masked to treatment allocation did a compression duplex ultrasound (CDU) of both legs at 7 to 10 days and, wherever practical, at 25 to 30 days after enrolment.

Care-givers and patients were not masked to treatment assignment. Patients were followed up for 6 months to determine survival and later symptomatic VTE. The primary outcome was a DVT in the proximal veins detected on a screening CDU or any symptomatic DVT in the proximal veins, confirmed on imaging, within 30 days of randomization. Patients were analyzed according to their treatment allocation. Between December 8, 2008, and September 6, 2012, a total of 2,876 patients were enrolled in 94 centers in the United Kingdom.

The included patients were broadly representative of immobile stroke patients admitted to hospital and had a median age of 76 years (IQR 67 to 84).

The primary outcome occurred in 122 (8.5 %) of 1,438 patients allocated IPC and 174 (12.1 %) of 1,438 patients allocated no IPC; an absolute reduction in risk of 3.6 % (95 % confidence interval [CI]: 1.4 to 5.8).

Excluding the 323 patients who died before any primary outcome and 41 without any screening CDU, the adjusted odds ratio (OR) for the comparison of 122 of 1,267 patients versus 174 of 1,245 patients was 0.65 (95 % CI: 0.51 to 0.84; p = 0·001).

Deaths in the treatment period occurred in 156 (11 %) patients allocated IPC and 189 (13 %) patients allocated no IPC died within the 30 days of treatment period (p = 0.057); skin breaks on the legs were reported in 44 (3 %) patients allocated IPC and in 20 (1 %) patients allocated no IPC (p = 0.002); falls with injury were reported in 33 (2 %) patients in the IPC group and in 24 (2 %) patients in the no-IPC group (p = 0.221).

the authors concluded that IPC is an effective method of reducing the risk of DVT and possibly improving survival in a wide variety of patients who are immobile after stroke. It is interesting to note that an Up To Date review on “Prevention of venous thromboembolic disease in medical patients” (Pai and Douketis, 2014) states that “Data on the efficacy and safety of IPCs are limited. However, one large randomized trial in patients with stroke suggested that IPCs reduce the incidence of VTE [Dennis et al, 2013].

A multicenter, randomized trial of 2,876 immobile patients with acute stroke (CLOTS 3) reported that, compared to no device, IPC use was associated with a lower rate of VTE at 30 days (12 versus 8.5 percent; absolute risk reduction 3.6 percent; 95% CI 1.4 to 5.8) without altering mortality (13 versus 11 percent).

While use of low molecular weight heparin was similar in both groups (32 versus 30 percent), more patients in the IPC group wore compression stockings (15 versus 6 percent) which may have biased results in favor of IPC use”.

Critical Limb Ischemia: In a systematic review, Abu Dabrh and associates (2015) synthesized the existing evidence about various non-revascularization-based therapies used to treat patients with severe or critical limb ischemia (CLI) who are not candidates for surgical revascularization. These investigators searched multiple databases through November 2014 for RCTs and non-randomized studies comparing the effect of medical therapies (prostaglandin E1 and angiogenic growth factors) and devices (pumps and spinal cord stimulators).

They reported ORs and 95 % Cis of the outcomes of interest pooling data across studies using the random effects model. These researchers included 19 studies that enrolled 2,779 patients; none of the non-revascularization-based treatments was associated with a significant effect on mortality.

Intermittent pneumatic compression (OR, 0.14; 95 % CI: 0.04 to 0.55) and spinal cord stimulators (OR, 0.53; 95 % CI: 0.36 to 0.79) were associated with reduced risk of amputation. A priori established subgroup analyses (combined versus single therapy; randomized versus non-randomized) were not statistically significant.

The authors concluded that very low-quality evidence, mainly due to imprecision and increased risk of bias, suggested that IPC and spinal cord stimulators may reduce the risk of amputations; and evidence supporting other medical therapies is insufficient. Moran and colleagues (2015) stated that IPC is designed to aid wound healing and limb salvage for patients with CLI who are not candidates for revascularisation. These researchers conducted a systematic review of the literature to identify and critically appraise the evidence supporting its use in this population.

A search was conducted in Embase, MEDLINE and clinical trial registries up to the end of March 2013. No date or language restrictions were applied. Quality assessment was performed by 2 investigators independently.

Quality was assessed using the Cochrane risk of bias tool and the NICE case-series assessment tool. Two controlled before-and-after (CBA) studies and 6 case series were identified. One retrospective CBA study involving compression of the calf reported improved limb salvage and wound healing (OR 7.00, 95 % CI: 1.82 to 26.89, p < 0.01).

One prospective CBA study involving sequential compression of the foot and calf reported statistically significant improvements in claudication distances and SF-36 quality of life scores. No difference in all-cause mortality was found. Complications included pain associated with compression, as well as skin abrasion and contact rash as a result of the cuff rubbing against the skin.

All studies had a high risk of bias. The authors concluded that the limited available results suggested that IPC may be associated with improved limb salvage, wound healing and pain management. However, they stated that in the absence of additional well-designed analytical studies examining the effect of IPC in CLI, this treatment remains unproven.

CPT Codes / HCPCS Codes / ICD-10 Codes Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by ""+"": Information in the [brackets] below has been added for clarification purposes.

Codes requiring a 7th character are represented by ""+"": Code Code Description Other CPT codes related to the CPB:29581 Application of multi- layer compression system; leg (below knee), including ankle and foot29582 thigh and leg, including ankle and foot, when performed HCPCS codes covered if selection criteria are met: A4600 Sleeve for intermittent limb compression device, replacement only, each E0650 Pneumatic compressor; non- segmental home model E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure E0660 Non- segmental pneumatic appliance for use with pneumatic compressor; full leg E0666 Non- segmental pneumatic appliance for use with pneumatic compressor, half leg E0667 Segmental pneumatic appliance for use with pneumatic compressor, full leg E0669 Segmental pneumatic appliance for use with pneumatic compressor, half leg E0671 Segmental gradient pressure pneumatic appliance; full leg E0673 Segmental gradient pressure pneumatic appliance, half leg E0676 Intermittent limb compression device (includes all accessories), not otherwise specified [not covered for single patient use pneumatic compression device]HCPCS codes not covered for indications listed in the CPB: E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)Other HCPCS codes related to the CPB: A6530 - A6549 Gradient compression stockings ICD- 10 codes covered if selection criteria are met: I83.001 - I83.229 Varicose veins of lower extremities I87.311 - I87.319 Chronic venous hypertension (idiopathic) with ulcer I87.331 - I87.339 Chronic venous hypertension (idiopathic) with ulcer and inflammation Z74.01 Bed confinement status [covered for members who are bedridden due to trauma, orthopedic surgery, neurosurgery or other circumstances preventing ambulation]ICD- 10 codes not covered for indications listed in the CPB: G25.81 Restless leg syndrome I69.098,I69.198,I69.298I69.398,I69.898,I69.998Other sequelae of cerebrovascular disease I70.201 - I70.799 Atherosclerosis I73.00 - I73.9,I77.70 - I77.79,I79.1 - I79.8Other peripheral vascular disease I74.2 - I74.4 Embolism and thrombosis of arteries of the extremities I99.8 Other disorder of circulatory system [critical limb ischemia]M62.20 - M62.28 Other disorder of circulatory system [critical limb ischemia]S52.501A - S52.509A Unspecified [closed] fracture of the lower end of radius [Dupuytren's fracture]T79.6xx A - T79.6xx S Traumatic ischemia of muscle Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits The above policy is based on the following references: De Lisa J, ed.

Rehabilitation Medicine: Principles and Practice. 2 nd ed. Philadelphia, PA: J. B. Lippincott Co. 1993;1095-1096. Mc Culloch JM, Marler KC, Neal MB, et al. Intermittent pneumatic compression improves ulcer healing. Adv Wound Care. 1994;7 (4):22-24, 26. Dickey JW. Stasis ulcers: The role of compliance in healing.

Southern Med J. 1991;84 (5):557-561. Allsup DJ. Use of the intermittent pneumatic compression device in venous ulcer disease. J Vasc Healing. 1994;12 (4):106-111. Comerota AJ, Katz ML, White JV. Why does prophylaxis with external pneumatic compression for deep venous thrombosis fail?

Am J Surg. 1992;164 (3):265-268. Ilgenfritz FM, Meier JR. Venous velocity increase with a pneumatic foot compression garment. Angiology. 1994;45 (11):949-952. Nelson E, Jones J. Venous leg ulcers. In: BMJ Clinical Evidence.

London, UK: BMJ Publishing Group; September 2007. Ramos J, Perrotta C, Badariotti G, Berenstein G. Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy. Cochrane Database Syst Rev. 2008; (4): CD005259. Nelson EA, Mani R, Vowden K. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev. 2008; (2): CD001899. Whitelaw GP, Oladipo OJ, Shah BP, et al. Evaluation of intermittent pneumatic compression devices.

Orthopedics. 2001;24 (3):257-261. Larson CM, Mac Millan DP, Lachiewicz PF. Thromboembolism after total knee arthroplasty: Intermittent pneumatic compression and aspirin prophylaxis. J South Orthop Assoc. 2001;10 (3):155-163. Vowden K. The use of intermittent pneumatic compression in venous ulceration.

Br J Nurs. 2001;10 (8):491-509. Kumar S, Walker MA. The effects of intermittent pneumatic compression on the arterial and venous system of the lower limb: A review. J Tissue Viability. 2002;12 (2):58-60, 62-66. Kumar S, Samraj K, Nirujogi V, et al. Intermittent pneumatic compression as an adjuvant therapy in venous ulcer disease. J Tissue Viability. 2002;12 (2):42-44, 46, 48 passim. Tri Centurion, LLC. Pneumatic compression devices.

Local Coverage Determination No. L11503. Medicare Durable Medical Equipment Program Safeguard Contractor (DME PSC). Columbia, SC: Tri Centurion; revised January 1, 2007. Center for Medicare and Medicaid Services (CMS). Pneumatic compression pumps for venous insufficiency (#CAG-00075N). Decision Memorandum. National Coverage Analysis (NCA). Baltimore, MD: CMS; October 17, 2001. Abdulwadud O. Is intermittent calf compression better than electrical calf stimulation in preventing deep vein thrombosis in high-risk surgical patients?.

Evidence Centre Critical Appraisal. Clayton, VIC: Centre for Clinical Effectiveness (CCE); 2001. Berliner E, Berrin O, Zarin D. A systematic review of pneumatic compression for treatment of chronic venous insufficiency and venous ulcers. J Vasc Surg. 2003;37:539-544. Canadian Coordinating Office of Health Technology Assessment (CCOHTA). Pneumatic compression therapy on venous insufficiency. Pre-assessment No. 27. Ottawa, ON: CCOHTA; January 2004. Handoll HHG, Farrar MJ, Mc Birnie J, et al. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures.

Database Syst Rev. 2002; (4): CD000305. Wille-Jørgensen P, Rasmussen MS, Andersen BR, Borly L. Heparins and mechanical methods for thromboprophylaxis in colorectal surgery. Cochrane Database Syst Rev. 2004; (1): CD001217. Kolbach DN, Sandbrink MWC, Neumann HAM, Prins MH. Compression therapy for treating stage I and II (Widmer) post-thrombotic syndrome. Cochrane Database Syst Rev. 2003; (4): CD004177. Mazzone C, Chiodo Grandi F, Sandercock P, et al. Physical methods for preventing deep vein thrombosis in stroke. Cochrane Database Syst Rev. 2004; (4): CD001922. Labropoulos N, Wierks C, Suffoletto B. Intermittent pneumatic compression for the treatment of lower extremity arterial disease: A systematic review.

Vasc Med. 2002;7 (2):141-148. Agency for Healthcare Research and Quality (AHRQ). Pneumatic compression for treatment of chronic venous insufficiency and venous ulcers - systematic review. Technology Assessment. Rockville, MD: AHRQ; 2001. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

Chest. 2004;126 (3 Suppl):338S-400S. Ramaswami G, D'Ayala M, Hollier LH, et al. Rapid foot and calf compression increases walking distance in patients with intermittent claudication: Results of a randomized study. J Vasc Surg. 2005;41 (5):794-801. Kakkos SK, Geroulakos G, Nicolaides AN. Improvement of the walking ability in intermittent claudication due to superficial femoral artery occlusion with supervised exercise and pneumatic foot and calf compression: A randomised controlled trial.

Eur J Vasc Endovasc Surg. 2005;30 (2):164-175. Kakkos SK, Caprini J, Geroulakos G, et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high risk patients.

Cochrane Database Syst Rev. 2008; (4): CD005258. Gonzalez AI, Bermejo C, Blanco A, et al. Physical treatments for non-complicated chronic venous insufficiency (Protocol for Cochrane Review). Cochrane Database Syst Rev. 2003; (4): CD004438. Danish SF, Burnett MG, Ong JG, et al. Prophylaxis for deep venous thrombosis in craniotomy patients: A decision analysis.

Neurosurgery. 2005;56 (6):1286-1292; discussion 1292-1294. Lieberman JR, Hsu WK. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2005;87 (9):2097-2112. Mundy L, Merlin T, Parrella A. Art Assist: Intermittent pneumatic limb compression device for lower limb ischaemia and peripheral vascular disease in patients with diabetes.

Horizon Scanning Prioritising Summary - Volume 6. Adelaide, SA: Adelaide Health Technology Assessment (AHTA) on behalf of National Horizon Scanning Unit (Health PACT and MSAC); 2004. Roderick P, Ferris G, Wilson K, et al. Towards evidence-based guidelines for the prevention of venous thromboembolism: Systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis.

Health Technol Assess. 2005;9 (49):1-94. Kalodiki E, Ellis M, Kakkos SK, et al. Immediate hemodynamic effect of the additional use of the SCD EXPRESS Compression System in patients with venous ulcers treated with the four-layer compression bandaging system.

Eur J Vasc Endovasc Surg. 2007;33 (4):483-487. Rajendran S, Rigby AJ, Anand SC. Venous leg ulcer treatment and practice--Part 3: The use of compression therapy systems. J Wound Care. 2007;16 (3):107-109. Lachiewicz PF, Soileau ES. Mechanical calf compression and aspirin prophylaxis for total knee arthroplasty.

Clin Orthop Relat Res. 2007;464:61-64. Bern M, Deshmukh RV, Nelson R, et al. Low-dose warfarin coupled with lower leg compression is effective prophylaxis against thromboembolic disease after hip arthroplasty. J Arthroplasty. 2007;22 (5):644-650. Kavros SJ, Delis KT, Turner NS, et al. Improving limb salvage in critical ischemia with intermittent pneumatic compression: A controlled study with 18-month follow-up.

J Vasc Surg. 2008;47 (3):543-549. Partsch H, Flour M, Smith PC; International Compression Club. Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence. Under the auspices of the IUP. Int Angiol. 2008;27 (3):193-219. Morris RJ. Intermittent pneumatic compression - systems and applications. J Med Eng Technol. 2008;32 (3):179-188. Geerts WH, Bergqvist D, Pineo GF, et al; American College of Chest Physicians.

Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133 (6 Suppl):381S-453S. Khanna A, Gougoulias N, Maffulli N. Intermittent pneumatic compression in fracture and soft-tissue injuries healing.

Br Med Bull. 2008;88 (1):147-156. Lettieri CJ, Eliasson AH. Pneumatic compression devices are an effective therapy for restless legs syndrome: A prospective, randomized, double-blinded, sham-controlled trial. Chest. 2009;135 (1):74-80. Morris RJ, Woodcock JP. Intermittent pneumatic compression or graduated compression stockings for deep vein thrombosis prophylaxis?

A systematic review of direct clinical comparisons. Ann Surg. 2010;251 (3):393-396.de Haro J, Acin F, Florez A, et al. A prospective randomized controlled study with intermittent mechanical compression of the calf in patients with claudication. J Vasc Surg. 2010;51 (4):857-862. Nelson EA, Mani R, Thomas K, Vowden K. Intermittent pneumatic compression for treating venous leg ulcers.

Cochrane Database Syst Rev. 2011;2: CD001899.te Slaa A, Dolmans DE, Ho GH, et al. Prospective randomized controlled trial to analyze the effects of intermittent pneumatic compression on edema following autologous femoropopliteal bypass surgery. World J Surg. 2011;35 (2):446-454. Falck-Ytter Y, Francis CW, Johanson NA, et al; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141 (2 Suppl):e278S-e325S. Cambier DC, De Corte E, Danneels LA, Witvrouw EE. Treating sensory impairments in the post-stroke upper limb with intermittent pneumatic compression. Results of a preliminary trial. Clin Rehabil. 2003;17 (1):14-20. Pfizenmaier DH 2nd, Kavros SJ, Liedl DA, Cooper LT. Use of intermittent pneumatic compression for treatment of upper extremity vascular ulcers. Angiology. 2005;56 (4):417-422. Handoll HH, Madhok R, Howe TE. Rehabilitation for distal radial fractures in adults. Cochrane Database Syst Rev. 2006; (3): CD003324. Doyle S, Bennett S, Fasoli SE, Mc Kenna KT. Interventions for sensory impairment in the upper limb after stroke. Cochrane Database Syst Rev. 2010; (6): CD006331. Dennis M, Sandercock P, Reid J, et al; CLOTS Trials Collaboration. Does intermittent pneumatic compression reduce the risk of post stroke deep vein thrombosis? The CLOTS 3 trial: Study protocol for a randomized controlled trial. Trials. 2012;13:26. Lansberg MG, O'Donnell MJ, Khatri P, et al; American College of Chest Physicians. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141 (2 Suppl):e601S-e636S. Zhao JM, He ML, Xiao ZM, et al. Different types of intermittent pneumatic compression devices for preventing venous thromboembolism in patients after total hip replacement. Cochrane Database Syst Rev. 2012;11: CD009543. CLOTS (Clots in Legs Or s Tockings after Stroke) Trials Collaboration, Dennis M, Sandercock P, Reid J, et al. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): A multicentre randomised controlled trial. Lancet. 2013;382 (9891):516-524. Pai M, Douketis JD. Prevention of venous thromboembolic disease in medical patients. Up To Date [online serial]. Waltham, MA: Up To Date; reviewed March 2014. Abu Dabrh AM, Steffen MW, Asi N, et al. Nonrevascularization-based treatments in patients with severe or critical limb ischemia. J Vasc Surg. 2015;62 (5):1330-1339. Moran PS, Teljeur C, Harrington P, Ryan M. A systematic review of intermittent pneumatic compression for critical limb ischaemia. Vasc Med. 2015;20 (1):41-50. O'Connell S, Bashar K, Broderick BJ, et al. The use of intermittent pneumatic compression in orthopedic and neurosurgical postoperative patients: A systematic review and meta-analysis. Ann Surg. 2016;263 (5):888-889. Pavon JM, Adam SS, Razouki ZA, et al. Effectiveness of intermittent pneumatic compression devices for venous thromboembolism prophylaxis in high-risk surgical patients: A systematic review. J Arthroplasty. 2016;31 (2):524-532. Policy History Last Review 07/11/2017Effective: 04/27/2001Next Review: 05/10/2018Review History Definitions Additional Information Clinical Policy Bulletin Notes "

Medicare Part B (Medical Insurance) covers power-operated vehicles (scooters) and manual wheelchairs as durable medical equipment (DME) that your doctor prescribes for use in your home.

Scooters For Seniors: Does Medicare Pay For My Scooter?

Scooters For Seniors: Does Medicare Pay For My Scooter? Aug 3, 2015 9 Comments Sign up for our newsletter!Get The Senior List news and latest offers straight to your inbox!Name Email*Submit Share 100 Tweet +1 Pin 4 Share 10Where did all the advertisements for scooters go?

New rules have made it harder and harder for Medicare to cover scooters for seniors. It wasn’t so long ago that a prominent “scooter store” got itself in a pickle for pushing doctors to write prescriptions for Medicare furnished scooters (whether necessary or not). Scrutiny surrounding The Scooter Store case has led to tighter restrictions on Medicare covered scooters, making eligibility for these scooters a complicated issue to wade through.

Here’s CBS News discussing The Scooter Store’s advertisements which targeted seniors all over the country: Some members of Congress say the ads lead to hundreds of millions of dollars in unnecessary spending by Medicare, which is only supposed to pay for scooters as a medical necessity when seniors are unable to use a cane, walker or regular wheelchair.

According to congressional testimony, Medicare accounted for about 75 percent of The SCOOTER Store’s revenue.

– CBS News The Medicare spending issues surrounding scooters and other durable medical equipment (DME) led to tighter restrictions on where you can purchase scooters for seniors, who is eligible for Medicare reimbursement, and the steps you need to take in order to be in compliance with Medicare Part B (medical insurance) rules.

Let’s dig into the details…Who is eligible for a Scooter covered by Medicare? Medicare.gov says that all people who meet criteria with Medicare Part B are covered for scooters (which they define as “manual wheelchairs & power mobility devices”). RELATED: QUESTIONS TO ASK BEFORE BUYING A SCOOTERWhat steps do I need to take? Keep these facts in mind as you consider the steps you need to take when considering a scooter for mobility;

You must have a face-to-face examination and a written prescription from a doctor or other treating provider before Medicare helps pay for a power wheelchair. Power wheelchairs are covered only when they’re medically necessary. Advertisement Where can I purchase a scooter?

You can purchase a scooter anywhere you wish if you’re paying out of pocket. You can find them online (new and used) or you can visit your local DME supplier in town. If you’re planning on some help from Medicare however, you need to visit an enrolled DME supplier that accepts the assignment cost from the federal government.

Here’s more: Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them.

It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment. If suppliers don’t accept assignment, there’s no limit on the amount they can charge you. – Medicare.gov How much will it cost me?

If your DME provider accepts the Medicare assignment costs, you’ll be paying 20% of the Medicare-approved amount, and then the Part B deductible applies.

Medicare.gov says, “ depending on the type of equipment, you may need to rent the equipment, you may need to buy the equipment, or you may be able to choose whether to rent or buy the equipment .” After you’ve visited your (Medicare enrolled) doctor, and he/she has written you a prescription for a scooter, you can obtain details from a (Medicare enrolled) DME provider, and they can share options with you. General prices for a decent (new) scooter will range from $750-$2,000. The bottom line Medicare is making it more difficult for folks who want help purchasing a scooter today.

One of our community members “Dennis” who owns Towson Medical Equipment Company has this to say about Medicare reimbursement for scooters; “Medicare rarely pays for senior scooters. We submit claims all the time and they always deny them. You will end up paying out of pocket for a senior scooter.” So the best thing you can do today if you feel you’re eligible for Medicare assistance is to follow the new strict guidelines and work with a sanctioned DME provider in your local community.

If you have tips to share, or would like to comment on this issue (or other mobility issues) give us a shout in the comments below. If you’re considering buying a scooter, make sure you read The Top 10 Questions to Ask When Evaluating Scooters for Seniors. Advertisement Advertisement Filed Under: Home Care

How often is it covered? Medicare Part B (Medical Insurance) covers power-operated vehicles (scooters) and manual wheelchairs as durable medical equipment (DME) that your doctor prescribes for use in your home. You must have a face-to-face examination and a written prescription from a doctor or other treating provider before Medicare helps pay for a power wheelchair.

Your Medicare Coverage

Power wheelchairs are covered only when they're medically necessary. Note You may have to get prior approval (known as “prior authorization”) for certain types of power wheelchairs. Under this program, only 2 types of power wheelchairs require “prior authorization” before Medicare will pay for them: K0856: Power wheelchair, group 3 std., single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds K0861: Power wheelchair, group 3 std., multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds Your DME supplier will need to: Request “prior authorization”Send the request and required documents to Medicare You don’t need to do anything.

If your physician prescribes one of these wheelchairs to you, your DME supplier will, in most cases, submit a prior authorization request and all documentation to Medicare on your behalf. Medicare will review the information to make sure that you’re eligible and meet all requirements for the power wheelchair. Your Medicare coverage and benefits will stay the same, and you shouldn’t experience delays getting the items you need.

Your prior authorization request may be denied if: Medicare finds you don’t medically require a power wheelchair Medicare doesn’t get all the information needed to make a decision If additional information is needed, your DME supplier may resubmit your prior authorization request. For more information, call 1-800-MEDICARE. Who's eligible? All people with Part B are covered. Your costs in Original Medicare If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies.

Medicare pays for different kinds of DME in different ways. Depending on the type of equipment: You may need to rent the equipment. You may need to buy the equipment. You may be able to choose whether to rent or buy the equipment.

Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare.

If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them. It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment.

If suppliers don't accept assignment, there’s no limit on the amount they can charge you. Competitive Bidding Program If you live in or visit certain areas, you may be affected by Medicare's Competitive Bidding Program . In most cases, Medicare will only help pay for these equipment and supplies if they're provided by contract suppliers when both of these apply: You have Original Medicare. You get competitively bid equipment and supplies in competitive bidding areas. Contract suppliers can't charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.

Note If your current supplier isn't a Medicare contract supplier, you may still be able to stay with that supplier if they decide to participate in the program as a ""grandfathered"" supplier.

Suppliers that don't get Medicare contracts can decide to become ""grandfathered"" suppliers. This means a supplier may continue to rent equipment to you if you were renting the equipment when the program started.

This rule applies to oxygen, oxygen equipment, and certain rented equipment. You may continue using the ""grandfathered"" supplier until the rental period for your equipment ends. If you start renting additional equipment from a ""grandfathered"" supplier after the program starts, Medicare won't pay for the new equipment.

If you're renting equipment that's eligible for grandfathering, your supplier will let you know in writing 30 business days before the program begins whether it will or won't become a ""grandfathered"" supplier. What happens if my supplier decides not to become a grandfathered supplier? You need to decide whether to continue to rent from your current supplier and pay all the costs, or switch to a Medicare contract supplier.

A supplier that doesn’t have a contract and decides not to become a grandfathered supplier is required to notify you and pick up the item from your home after the program starts.

Your supplier must notify you these 3 ways before it can pick up the item: The supplier must send you a letter at least 30 business days before the program starts telling you that it will no longer provide rental items to you after a certain date. This letter will tell you the date that a Medicare contract supplier must start to provide you with the rented item.

The supplier must call you 10 days before picking up the item to make arrangements for pick up at an agreed upon time.

The supplier must call you again 2 business days before picking up the item. A supplier that isn’t grandfathered can't pick up a medically necessary item before the end of the last rental month for which the supplier is eligible to get a rental payment. If you change to a Medicare contract supplier, your old supplier should work with the contract supplier so there isn’t a break in service. Keep the pickup slip or other documentation from the old supplier that shows you no longer have the item.

Under current Medicare rules, you own these types of equipment after renting for 13 months. When you switch to a Medicare contract supplier instead of using a ""grandfathered"" supplier or other non-contract supplier, your 13-month rental period will start over.

So, you won't own the equipment until after the new rental period ends. This will extend your rental period and result in additional months of coinsurance. However, the amount you pay may be lower because the amount you'll pay will be based on the new payment rates under the new program.

Once you own the equipment, you must get replacement supplies and accessories for the equipment from a contract supplier in order for Medicare to help you pay for these items.

You may get repairs for the equipment you own from any Medicare-approved supplier (even a non-contract supplier), including replacement parts needed for the repair. If you already own your equipment, you must use a Medicare contract supplier for your replacement supplies and accessories.

Find a Medicare contract supplier. Note To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like: Other insurance you may have How much your doctor charges Whether your doctor accepts assignment The type of facility Where you get your test, item, or service Related resources Where to get covered DME items More information about DMECompetitive Bidding Program "

A supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient's use in the home and that are usable for an extended period of time.

Medical Supplies and Durable Medical Equipments - Address and Contact Information

Medical Supplies and Durable Medical Equipments - Address and Contact Information Home All Providers Medical Supplies Filter Results Filter By State: Alaska (152)Alabama (1281)Arkansas (834)American Samoa (6)Arizona (1318)California (5626)Colorado (1127)Connecticut (696)District Of Columbia (110)Delaware (202)Florida (6618)Georgia (2294)Guam (8)Hawaii (264)Iowa (818)Idaho (371)Illinois (2736)Indiana (1610)Kansas (699)Kentucky (1133)Louisiana (1329)Massachusetts (1006)Maryland (1236)Maine (244)Michigan (2544)Minnesota (1301)Missouri (1391)Northern Mariana Islands (9)Mississippi (898)Montana (285)North Carolina (2026)North Dakota (152)Nebraska (466)New Hampshire (301)New Jersey (1787)New Mexico (385)Nevada (572)New York (3798)Ohio (2648)Oklahoma (1038)Oregon (855)Pennsylvania (2703)Puerto Rico (885)Rhode Island (170)South Carolina (1357)South Dakota (243)Tennessee (1694)Texas (6897)Utah (591)Virginia (1558)Virgin Island (22)Vermont (113)Washington (1273)Wisconsin (1495)West Virginia (424)Wyoming (143)Medical Supplies and Durable Medical Equipments in USA71743 suppliers found.

Showing 1 - 20REGENTS OF THE UNIVERSITY OF UCEyewear Supplier (Equipment, not the service) NPI Number: 1003001439Address: 9415 Campus Point Dr, , La Jolla, CA, 92093 Phone: 858-450-6532 Fax: 619-291-3937BUFFALO ORTHOPEDIC BRACE, INC. Prosthetic/Orthotic Supplier NPI Number: 1003002973Address: 6140 Transit Rd, , Depew, NY, 14043 Phone: 716-681-1000 Fax: 716-681-5999EYESFIRST VISION CENTERDurable Medical Equipment & Medical Supplies NPI Number: 1003003179Address: 3391 State Route 27, , Franklin Park, NJ, 08823 Phone: 732-940-0900 Fax: --RELIABLE MEDICAL SUPPLIESDurable Medical Equipment & Medical Supplies NPI Number: 1003003278Address: 623 S Lake St, , Mundelein, IL, 60060 Phone: 847-566-0800 Fax: 847-566-0866DE GINO CORPORATION LLCDurable Medical Equipment & Medical Supplies NPI Number: 1003004052Address: 7447 Harwin Dr, Suite 220c, Houston, TX, 77036 Phone: 713-600-0606 Fax: 713-600-0607HAMILTON-MADISON, INC.

Durable Medical Equipment & Medical Supplies - Customized Equipment NPI Number: 1003004219Address: 105 1/2 E. State Street, , Pendleton, IN, 46064 Phone: 317-617-1248 Fax: --FMT MEDICAL EQUIPMENT CORPDurable Medical Equipment & Medical Supplies NPI Number: 1003004680Address: 11117 W Okeechobee Rd, Suite 207, Hialeah Gardens, FL, 33018 Phone: 305-818-2600 Fax: 305-818-2601PIGGLY WIGGLY PHARMACY #16Durable Medical Equipment & Medical Supplies NPI Number: 1003004995Address: 15 West Ashland Ave., , Andrews, SC, 29510 Phone: 843-264-3291 Fax: 843-264-5425VNA HOME MEDICALDurable Medical Equipment & Medical Supplies NPI Number: 1003005224Address: 700 Cooper Ave, , Saginaw, MI, 48602 Phone: 989-583-6017 Fax: --BREASTFEEDING CONCEPTSDurable Medical Equipment & Medical Supplies NPI Number: 1003005695Address: 3957 Fortner St, , Dothan, AL, 36305 Phone: 334-685-7192 Fax: --CLEVELAND CLINIC INDEPENDENCE BROADVIEW HTSDurable Medical Equipment & Medical Supplies NPI Number: 1003005869Address: 2001 E Royalton Rd, , Broadview Heights, OH, 44147 Phone: 440-717-6125 Fax: 440-717-6127PEARLE VISION #C6614Eyewear Supplier (Equipment, not the service) NPI Number: 1003006438Address: 4192 Conroy Rd, Shoppes At Millenia Ste#109, Orlando, FL, 32839 Phone: 407-352-0679 Fax: --ROVAJO ENTERPRISE, INC.

Durable Medical Equipment & Medical Supplies NPI Number: 1003006560Address: 7056 Kearny Dr, , Huntington Beach, CA, 92648 Phone: 800-225-9080 Fax: --DYMON HEARING CENTERHearing Aid Equipment NPI Number: 1003007162Address: 71 Walnut Blvd Ste 108, , Rochester, MI, 48307 Phone: 248-652-1208 Fax: --LAWRENCE VASQUEZ MERCY MEDICAL CAREDurable Medical Equipment & Medical Supplies NPI Number: 1003007519Address: 1 S Broadway, Suite 305, Edmond, OK, 73034 Phone: 405-513-8727 Fax: 405-513-8728CALIFORNIA SLEEP SOLUTIONSDurable Medical Equipment & Medical Supplies NPI Number: 1003008384Address: 9230 Bruceville Rd, Suite 4, Elk Grove, CA, 95758 Phone: 916-789-0112 Fax: 916-789-0529ATHENS OPTICAL INCEyewear Supplier (Equipment, not the service) NPI Number: 1003008749Address: 957 Baxter St, , Athens, GA, 30606 Phone: 706-549-4457 Fax: 706-353-3168EYE 20 OPTICAL INCEyewear Supplier (Equipment, not the service) NPI Number: 1003008756Address: 155 Se Loop 338, Suite 300, Odessa, TX, 79762 Phone: 432-367-5116 Fax: 432-367-0129LIBERTY MEDICAL SPECIALTIES, INC. Durable Medical Equipment & Medical Supplies NPI Number: 1003009069Address: 1768 Highway 501, , Myrtle Beach, SC, 29577 Phone: 843-448-8315 Fax: --ENID EYE OPTICAL, INC. Durable Medical Equipment & Medical Supplies NPI Number: 1003011511Address: 615 E Oklahoma Ave, Suite 100, Enid, OK, 73701 Phone: 580-242-0511 Fax: 580-242-05241 2 3 4 5 6 7 8 9 10 11 »Search for Medical Equipment Suppliers Durable Medical Equipments and Medical Supplies What is a DME Supplier?

Eyewear Supplier An organization that provides spectacles, contact lenses, and other vision enhancement devices prescribed by an optometrist or ophthalmologist.

Prosthetic/Orthotic Supplier An organization that provides prosthetic and orthotic care which may include, but is not limited to, patient evaluation, prosthesis or orthosis design, fabrication, fitting and modification to treat limb loss for purposes of restoring physiological function and/or cosmesis or to treat a neuromusculoskeletal disorder or acquired condition. Hearing Aid Equipment The manufacture and/or sale of electronic hearing aids, their component parts, and related products and services on a national basis.

The CDME helps with basic repairs, troubleshooting, and home inspections for DME products like oxygen, transfer systems, enteral supplies, and wound care. Trained and certified DME specialists are highly valued in the DME industry as an assurance to patients and referral sources of professionalism and quality care.

DME Specialist (CDME)

DME Specialist (CDME)Current CDME? Visit our Continuing Education Page or Certification Renewal Page Profession Overview What is a Certified DME Specialist? The CDME demonstrates broad knowledge of the Durable Medical Equipment (DME) industry. What does a Certified DME Specialist do?

The CDME Scope of Practice provides greater detail regarding the role of a BOC Certified DME Specialist. What advantage does a DME supplier gain by having a CDME on staff? Differentiation in the market;Management of risk;Criteria for evaluating potential employees;Limiting of fraud, waste, and abuse;Increase in customer satisfaction;Assurance for referral sources; and Medicare human resources management standards require that technical personnel be knowledgeable, competent, and trained in order to deliver products.

A CDME will provide additional assurance of compliance. How to Become a CDME? To become a CDME, you will need to: Meeteligibility prerequisites Successfully complete the DME specialist candidateexam Attest to upholding the ethical standards in the Code of Ethics, honored by all BOC certificants Please consult the CDME Certification Process for full details on how to become certified.

Continuing Education Once you have earned CDME credential, you will need to demonstrate your commitment to professional growth by earning continuing education credits. The DME field is dynamic and evolving. Ongoing learning throughout your career is essential to keeping up with the latest technology and process improvements in your profession.

You can submit your CEUs online and view your CEU record immediately at My BOC, your personal web portal. Learn More About Becoming A BOC CDMEGet more info: BOC CDME Certification Process Eligibility Prerequisites Certification FAQs Exam Scheduling Get started now: Certification Application Apply Now Got a question? Call us at 877.776.2200Email us at cert@bocusa.org Staff List

If your supplier accepts assignment, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment: You may need to rent the equipment. You may need to buy the equipment.

Your Medicare Coverage

"Is my test, item, or service covered? Go Nebulizers & nebulizer medications How often is it covered? Medicare Part B (Medical Insurance) covers nebulizers (and some medicines used in nebulizers if considered reasonable and necessary).

These are covered as durable medical equipment (DME) that your doctor prescribes for use in your home. Who's eligible? All people with Part B are covered. Your costs in Original Medicare

You may be able to choose whether to rent or buy the equipment. Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them.

It’s also important to ask your suppliers if they participate in Medicare before you get DME. If suppliers are participating suppliers, they must accept assignment. If suppliers are enrolled in Medicare but aren’t “participating,” they may choose not to accept assignment.

If suppliers don't accept assignment, there’s no limit on the amount they can charge you. Competitive Bidding Program If you live in or visit certain areas, you may be affected by Medicare's Competitive Bidding Program . In most cases, Medicare will only help pay for these equipment and supplies if they're provided by contract suppliers when both of these apply: You have Original Medicare. You get competitively bid equipment and supplies in competitive bidding areas. Contract suppliers can't charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.

Note If your current supplier isn't a Medicare contract supplier, you may still be able to stay with that supplier if they decide to participate in the program as a ""grandfathered"" supplier.

Suppliers that don't get Medicare contracts can decide to become ""grandfathered"" suppliers. This means a supplier may continue to rent equipment to you if you were renting the equipment when the program started. This rule applies to oxygen, oxygen equipment, and certain rented equipment. You may continue using the ""grandfathered"" supplier until the rental period for your equipment ends.

If you start renting additional equipment from a ""grandfathered"" supplier after the program starts, Medicare won't pay for the new equipment. If you're renting equipment that's eligible for grandfathering, your supplier will let you know in writing 30 business days before the program begins whether it will or won't become a ""grandfathered"" supplier.

What happens if my supplier decides not to become a grandfathered supplier? You need to decide whether to continue to rent from your current supplier and pay all the costs, or switch to a Medicare contract supplier.

A supplier that doesn’t have a contract and decides not to become a grandfathered supplier is required to notify you and pick up the item from your home after the program starts. Your supplier must notify you these 3 ways before it can pick up the item: The supplier must send you a letter at least 30 business days before the program starts telling you that it will no longer provide rental items to you after a certain date.

This letter will tell you the date that a Medicare contract supplier must start to provide you with the rented item.

The supplier must call you 10 days before picking up the item to make arrangements for pick up at an agreed upon time.

The supplier must call you again 2 business days before picking up the item. A supplier that isn’t grandfathered can't pick up a medically necessary item before the end of the last rental month for which the supplier is eligible to get a rental payment. If you change to a Medicare contract supplier, your old supplier should work with the contract supplier so there isn’t a break in service. Keep the pickup slip or other documentation from the old supplier that shows you no longer have the item.

Under current Medicare rules, you own these types of equipment after renting for 13 months. When you switch to a Medicare contract supplier instead of using a ""grandfathered"" supplier or other non-contract supplier, your 13-month rental period will start over. So, you won't own the equipment until after the new rental period ends. This will extend your rental period and result in additional months of coinsurance. However, the amount you pay may be lower because the amount you'll pay will be based on the new payment rates under the new program.

Once you own the equipment, you must get replacement supplies and accessories for the equipment from a contract supplier in order for Medicare to help you pay for these items.

You may get repairs for the equipment you own from any Medicare-approved supplier (even a non-contract supplier), including replacement parts needed for the repair. If you already own your equipment, you must use a Medicare contract supplier for your replacement supplies and accessories. Find a Medicare contract supplier. Note To find out how much your test, item, or service will cost, talk to your doctor or health care provider.

The specific amount you’ll owe may depend on several things, like: Other insurance you may have How much your doctor charges Whether your doctor accepts assignment The type of facility Where you get your test, item, or service Related resources Where to get covered DME items More information about DMECompetitive Bidding Program Return to search results "

ion DMEOPS - Durable Medical Equipment, Orthotics Prosthetics, and Supplies DMERCA - Durable Medical Equipment Regional Carriers in Region ASADMERC - Statistical Analysis Durable Medical Equipment Regional Carrier DMAC - DME (Durable Medical Equipment) Medicare Administrative Contractor DIF - DMERC (Durable Medical Equipment Regional Carrier) Information Form DMEA - Durable Medical Equipment Attachment

What does DMERC mean?

"What does DMERC mean? DMERC means Durable Medical Equipment Regional Carrier This acronym/slang usually belongs to Scientific & Educational category.

Particularly in Science Abbreviations, Healthcare Abbreviations, Medicare Beneficiary Abbreviations, Astronomy Abbreviations Popularity0 (0 Votes)Was it useful? Share this page What is the abbreviation for Durable Medical Equipment Regional Carrier? Durable Medical Equipment Regional Carrier can be abbreviated as DMERCWhat does DMERC mean?

- Definition of DMERC - DMERC stands for Durable Medical Equipment Regional Carrier. By Acronyms And Slang.com Image Source: Image HTML: HTML with link: Share this picture: Tweet Most popular questions people look for before coming to this page Q: A: What does DMERC stand for? DMERC stands for ""Durable Medical Equipment Regional Carrier"". Q: A: How to abbreviate ""Durable Medical Equipment Regional Carrier""?

""Durable Medical Equipment Regional Carrier"" can be abbreviated as DMERC. Q: A: What is the meaning of DMERC abbreviation? The meaning of DMERC abbreviation is ""Durable Medical Equipment Regional Carrier"". Q: A: What is DMERC abbreviation? One of the definitions of DMERC is ""Durable Medical Equipment Regional Carrier"". Q: A: What does DMERC mean? DMERC as abbreviation means ""Durable Medical Equipment Regional Carrier"". Q: A: What is shorthand of Durable Medical Equipment Regional Carrier?

The most common shorthand of ""Durable Medical Equipment Regional Carrier"" is DMERC. You can also look at abbreviations and acronyms with word DMERC in term. Page Link Citation Styles Suggest New Abbreviations or Slang with similar meaning ADMEA - Alabama Durable Medical Equipment Associat

DME - Durable Medical Equipment DHME - Durable and Home Medical Equipment DMECs - Durable Medical Equipment Coding System DMEFS - Durable Medical Equipment Fee Schedule DMEPOS - Durable Medical Equipment Prosthetic Orthotics Supplies DMEPOS - Durable Medical Equipment Prosthetics and Supplies SADMERC - Statistical Analysis Durable Medical Equipment Regional Contractor DMEPOS - Durable Medical Equipment Prosthetic and Orthotic Suppliersdmes - Durable Medical Equipment Supplierdmepos - Durable Medical Equipment, Prosthetic, Orthotic and Supply DME MAC - DURABLE MEDICAL EQUIPMENT MEDICARE ADMINISTRATIVE CONTRACTORDMEPOS - Durable Medical Equipment Prosthetic, Orthotics & Supplies DMEPOS - Durable Medical Equipment, Prosthetics, Orthotics And Supplies "

. Co-insurance under Part B, including the 20 percent on doctor visits, emergency room visits, and durable medical equipment that Part B doesn’t cover. The result is that TRICARE For Life beneficiaries pay nothing out of pocket for most hospitalizations lasting less than 150 days, and for many routine medical costs and services. The general rule is that if Medicare covers most of it, TRICARE For Life covers the rest of it. Prescription Drug Coverage

Medical Benefits in Retirement â TRICARE For Life and Medicare

If you retire from service, though – even from Reserve or National Guard duty – you may be eligible for continued care into retirement via TRICARE For Life. TRICARE For Life is a supplementary medical insurance program designed for military retirees – even for those who are retired from the Reserves and National Guard. About Medicare To understand TRICARE For Life (TFL), you first need to understand a little about Medicare.

Medicare is a federal health insurance program for Americans age 65 or older, or who have been diagnosed with certain chronic medical ailments. It consists of four parts: Part ACovers inpatient hospitalization costs. It doesn’t cover long term care, specifically, except in very limited circumstances.

It does cover hospitals, hospice care, some home health care service, It’s usually free to the retiree (those who pay a premium pay as much as $451 per month, as of 2012), and most people are automatically enrolled in Medicaid when they turn 65.

Part A covers inpatient care in hospitals (such as critical access hospitals, inpatient rehabilitation facilities, and long-term care hospitals)Inpatient care in a skilled nursing facility (not custodial or long term care)Hospice care services Home health care services Inpatient care in a Religious Nonmedical Health Care Institution Medicare Part A doesn’t cover everything, even within these categories, though.

Frequent or lengthy hospitalizations can still put a crimp on a Medicare beneficiary’s budget – even with military retirement pay. There are copays and deductibles you need to be aware of: Hospital Deductible: $1,156 per spell of illness Hospital Coinsurance: Days 0-60: $0; Days 61-90: $289 per day; Days 91-150: $578 per day Skilled Nursing Facility Coinsurance: Days 0-20: $0; Days 21-100: $144.50 per day Part BPart B covers most of the costs associated with physician fees, lab fees and durable medical equipment costs.

Typically, Part B will pay 80 percent of the costs of these services, and leave you with 20 percent of the tab, though some services have a higher coinsurance amount. You’re automatically enrolled when you turn 65, in most cases. There is a premium for Part B coverage, though: $99.90 per month. There’s also an annual deductible of $140 every year. Part CMedicare Part C, also called Medicare Advantage, is a program that allows Medicaid beneficiaries to access their Medicaid benefits via a private managed care plan.

These plans are highly customizable, and allow Medicare beneficiaries to buy plans carefully tailored to meet their own individual circumstances. Premiums, deductibles and covered services vary with the plan. Part DPart D covers prescription drugs.

You are not automatically enrolled in Part D – you have to opt in. There is a monthly premium and complicated series of deductibles and co-pays, but Part D can provide substantial protection from the high costs of prescription drugs – particularly newer brand name drugs for which no generics are available.

TRICARE For Life Overview TRICARE for Life is designed for those active duty military retirees who have Medicare Part A, and reserve component military retirees, Medal of Honor recipients, and qualifying family members who have Medicaid Part A and Part B. TFL is designed to kick in where Medicare leaves off – providing coverage for acute medical services not covered under Medicare Part A or B. TRICARE For Life helps senior retirees by providing substantial coverage of items like these:100 percent of Medicare Part A hospitalization deductibles and co-pays through day 150, including mental health hospitalizations

TRICARE For Life covers medically necessary and appropriate prescription drugs. It’s almost never worth it for TFL beneficiaries to buy separate coverage under Medicare Part D, unless the beneficiary qualifies for free or reduced-price Part D coverage because of limited income or assets.

Medicare Supplement Plans and Medicare Advantage Generally, if you have TRICARE for Life, you don’t need Medicare supplement insurance or Medicare Advantage (Part C) plans, as they would just add additional premium expenses.

Generally, you only need Medicare A, B, Part D if you want prescription drug coverage, and perhaps one supplementary plan, such as a Medicare Supplement policy, Medicare Advantage, or TRICARE For Life. Note: To avoid penalties and maximize your eligibility for benefits, enroll in Part B as soon as you are eligible – especially if you are not an active duty retiree.

Exclusions TRICARE For Life does not cover long term care benefits, such as adult day care and most ordinary nursing home admissions.

But these costs can be significant, and even devastating for many military retirees unless they find some way to pay for needed long term care services. There are other long term care options available.

el. Purchasing Durable, Long-Lasting Medical Equipment The TRICARE Standard program can help cover some costs for medical equipment. Under the program, there are cost-shares for the monetary amount spent on purchasing necessary medical equipment and items such as hospital beds, wheelchairs, oxygen tanks, etc.

Items Included Under TRICARE Health Care Programs

Items Included Under TRICARE Health Care Programs TRICARE health care programs offer numerous benefits. Some examples of these benefits which are included in the health care include basic diagnostic and medical treatment.

However, these programs also encompass a number of other health related benefits under the TRICARE coverage plans. It is suggested that you contact a Health Benefits Advisor prior to receiving these health care benefits to know complete details about any restrictions or limitations so that you can make the best informed decision about which TRICARE plan to choose.

For Anthrax Immunizations Visit the webpage of https://www.vaccines.mil/Anthrax to find out more details regarding the Anthrax Vaccine Immunization Program for military personn

This medical equipment can be either purchased directly or you also have the option to rent or lease it. rented For covreage assistance, you must send a claim stating the reasons why you require the equipment and for the duration that it is required as well as other documented information.

This should be sent along with the doctor’s prescription for the item (s) needed. Annual Eye Exams for the Family Members of those in Active Service Duty One eye examination per year is avaiable to members who are in active military duty as well as each of their family members.

The eye examination will be performed to check thoroughly both the interior and exterior of the eyes and diagnose any problems with vision if there are any. Treatment and Diagnosis for Family Planning Under TRICARE, there is available assistance for family planning for birth control methods such as diaphragms, IUDS (intrauterine devices), birth control pills, shot injections, contraceptive implant systems, tubal litigations, pregnancy tests, vasectomies, etc.

The treatment and diagnosis for infertility is also covered by TRICARE health programs. TRICARE Standard Coverage for Genetic Testing for your Unborn Child The TRICARE Standard plan provides coverage for genetic testing for an unborn child in order to search for any possible defects.

TRICARE does not cover to test to find out the gender of the child or nor does it cover paternity testing.

The TRICARE Standard plan offers coverage only when you are more than 35 years of age and pregnant; you suffered from rubella during the first trimester of your pregnancy; or if either parent or a previous biological child has suffered from congenital defects, etc. Complete Home Health Care Services by TRICAREThe home health care program offered by TRICARE provides complete care and home health aid services for patients. This includes receiving the services of well-trained nursing staff, necessary care, as well as speech, physical, and occupational therapies, etc.

The duration that is covered by TRICARE is for about 28 hours per week for part-time health services or occasionally, at least 35 hours of aid per week. The home health agency will provide all of these home health care services and should be set up with a health care advisor.

Long-Term Health Insurance Coverage Health care insurance for a long-term period can be purchased by active duty military members and retired personnel, as well as for members of their families.

To obtain more details about long-term health insurance coverage, visit www.opm.gov/insure/ltc. Hospice Care Services for Terminally Ill Patients The TRICARE program also provides hospice care as an alternative choice for those patients who are terminally ill and whose life expectancy is less than 6 months.

A Medicare-approved service provides the hospice care which comprises of nursing care, physician services, counseling to the patients, medications, medical supplies, inpatient respite care, acute patient short-term care, services for home health aid, etc. Most hospice care services for patients are covered by the TRICARE Standard program and does not require meeting deductibles though it may require some cost-sharing for prescription medications.

Room and board at facilities is not covered during this time unless it is for inpatient or respite care. There is additional information available about hospice care. Coverage for Surgical Implants TRICARE also provides coverage for surgical implants that are approved by the FDA. Some of these surgical implants are the intraocular lenses implanted following a cataract surgery in the eye, cochlear implants that aid in hearing, penile implants, breast implants, implants to correct any birth malformations, correction of the reproductive organs, correction of the organic impotence, etc.

However, these procedures also may have some restrictions and limitations in the coverage offered through TRICARE for surgical implants. Pap Smears and Mammograms As a measure of preventive and diagnostic health care services, Pap smears tests and mammograms, etc. for women are also covered under TRICARE. Behavioral/Mental Health Care Services Psychological and mental health care services are also offered through TRICARE programs. Coverage varies based on the different types of behavioral or mental health care the patient requires.

Psychotherapy services forboth inpatient and outpatient treatments, care and treatment for substance abuse issues, care and treatment for adolescents and children up to 21 years old in authorized treatment centers (for a maximum of 150 days), etc.

are all scenarios which are covered under the TRICARE program. To learn more details about coverage, visit http://www.tricare.mil/Covered Services/Mental/Treatments.aspx. Types of Health Care Services NOT Covered by TRICAREThe TRICARE health care option doesn’t cover some types of health services. You can contact your Health Benefits Advisor, Beneficiary Counselor, or a TRICARE service center to know the complete list of services that TRICARE does not cover and considers them as exclusions.

These include: Acupuncture Abortions or Pregnancy Termination Methods Anabolic Steroids Post-Mortem or Autopsy Examinations Artificial Insemination Cosmetic Drugs Transplantation of Bone Marrow for Ovarian Cancer Treatment Plastic Surgery or Elective Cosmetic Surgery LASIK Surgery Experimental or Unproven Procedures Chronic Fatigue Syndrome Hearing Aids Podiatry Care Patient Counseling Services Vision Treatment Naturopathy Treatment Rest Cure in Private Hospital Rooms Health and Vitamin Supplements purchased Outside of a VA Facility Self-Help Courses Sex Changes Elective Psychotherapy or Mind Expansion Orthopedic Shoes and Other Supports Homes of Retirement OTC Drugs Psychiatric Therapy Speech and Occupational Therapy Products for Cessation of Smoking Treatment for Impotency or Sexual Dysfunction Management and Control of Weight Reversal Procedures of Surgical Sterilization Care Vitamins other than Niacin and Folic acid formulations and also injections of Vitamin B12, D, and K. Medical compensation reviews for workers School Physical Exams Physical exams can be obtained by dependents of the TRICARE-eligible servicemembers in the dependent’s schools.

These dependents must be more than 5 years of age and below the age of 12 years old. The TRICARE physical exam benefit doesn’t include those physical examinations conducted by schools which are required in order to take part in sports and other events.

Military Health Care FAQs If I live in locations like Alaska, Hawaii or the U. S. territory, is it possible to use the BWE (Beneficiary Web Enrollment) website? The BWE website can be accessed if you happen to live in locations such as Alaska or Hawaii in addition to the lower 48 states.

However, it but cannot be accessed in the U. S. territories and in other locations overseas. Where can my overseas claims be filed? In order to start the process of your claim, you can send your overseas claim bill and the form through mail to: Wisconsin Physician Services P. O. Box number 7985Madison, WI, 53707-7985In case I have issues with my claim and the processor of claims is not able to resolve the issue, who should I contact regarding this?

You can contact the Beneficiary Counseling and Assistance Coordinator (BCAC) or the regional contractor in case of any issues with the claim. You can also get in touch with the local military treatment facility (MTF) regarding this problem.

Also, you can contact your nearest Debt Collection Assistance Officer (DCAO) at the military treatment facility when a notice of negative credit is sent to you by a collection agency. In case my claim hasn’t been paid and has been sent to a collections agency, who can I contact to report this issue? The DCAO (Debt Collection Assistance Officer) at your local MTF can be contacted in situations when the collections agency sends a notice of negative credit due to a TRICARE bill.

Is it true that free health care services for two years can be received by combat veterans? Yes, it is true that free health care is provided to combat veterans by the VA. This benefit to combat veterans has been provided after November 11, 1998 for a five-year time period that commences from the date when the veteran parted from the service.

Is the shingles vaccine paid for by TRICARE? Yes., the shingles vaccine is paid by TRICARE as of October 19, 2007.

Can I visit a doctor other than my PCM (Primary Care Manager)? Yes. The benefits of the Point of Service will then be paid by TRICARE. In that case, an annual fee of $300 will be deducted and also a 50% cost-share will have to be paid by you after the annual deductible is met.

I also have other health care insurance while being enrolled in the TRICARE Prime plan. I need to know whether this will be my best choice. In the event that TRICARE Prime is your primary health care coverage plan, you can enjoy a number of benefits from the program. However, in the case that you have other health coverage plans, TRICARE health insurance is always considered to be secondary.

You can also discuss about your options with your representative at the local service center of TRICARE. Will I get benefits from TRICARE if I had no referral prior to visiting the hospital? Yes, you will be paid for benefits under the Point of Service option of TRICARE. However, an annual fee deductible of $300 or $600 for a family is applicable in addition to the 50% cost-share pay after the annual deductible has been met.

Does it apply to the maximum out-of-pocket expense in case I choose the Point of Service option during my visit to the doctor?

No. The cost sharing amounts and the Point Of Service annual deductible are not included in the maximum out-of-pocket expense in the year of enrollment, but it is credited to the fiscal year maximum. TRICARE Coverage for Skilled Nursing Facilities Skilled nursing facilities (SNF) are covered under the TRICARE health care plan for an unlimited period of time.

These SNF services can be offered only by skilled professionals under the direction of a doctor. The TRICARE plan provides coverage for rehabilitative therapies, skilled nursing care, medical equipment and devices, drug prescriptions, lab work, etc.

under the Skilled Nursing Facility benefit of TRICARE. TRICARE Coverage for Substance Abuse In the cases of substance abuse, coverage for detoxification is provided by TRICARE for a maximum of 7 days in a rehabilitation treatment facility. Also, a maximum of 21 days in rehabilitation is covered by the TRICARE Standard program. Filing Appeals with TRICARETRICARE decisions can be appealed in respect to the payment of claims or authorization for denial of services.

You can also contact your nearest TRICARE service center representative to learn more details about the appeal process. It is imperative that you remember these following tips when filing an appeal with TRICARE: All deadlines of the appeal must be met. You must file your appeal with TRICARE in written format with your signature on the appeal. While submitting the appeal, you must make sure that all the supporting documents are also included in it. Also, the letter must be sent before the deadline in case you don’t possess the documents. Make sure that you also have a copy of all documents. Sharetweet

For example, a policy may cover up to $150 / day for long term care. However, the definition of what long term care is varies with every policy. Fortunately, most policies consider the cost of medically necessary, durable or home medical equipment to be a covered long term care expense. Existing policy holders should check with their insurance providers to determine if durable medical equipment is covered.

How to Pay for Home and Durable Medical Equipment: a Comprehensive Guide

How to Pay for Home and Durable Medical Equipment: a Comprehensive Guide Page Reviewed / Updated - Jun.

2017Find Affordable Home Care Find Financial Help for Care Assistance for Wheelchairs Assistance for Walk In Tubs Assistance for Home Care Supplies Table of Contents Introduction Definitions and Terminology Prescriptions and DMEWho Determines What is Necessary Financial Assistance and Payment Options Medicare and Private Insurance Medicaid and HCBS Waivers Veterans Health Care and VA Insurance State Assistance Programs Non-Profits and Foundations Other Options Out-of-Pocket / Private Pay When Insurance Won't Pay Common Home Medical Equipment Costs Introduction As more Americans age in place, or remain living at home instead of moving into skilled nursing homes or assisted living residences, there has been an increased need for seniors to purchase home or durable medical equipment (DME).

Each year, approximately $100 Billion is spent on durable medical equipment in the U. S. Fifteen percent of which is paid for directly out-of-the-pocket of consumers.

It is the objective of this article to help individuals maximize the assistance they receive from their insurance coverage, find other financial assistance programs and minimize their out-of-pocket spending on DME. Definitions and Terminology

Prior to a discussion about paying for durable medical equipment, it is helpful to have a clear understanding of what durable medical equipment is and to define some of the related terms and acronyms. Durable Medical Equipment (DME) as well as the terms, Home Medical Equipment (HME) and home healthcare equipment are used interchangeably. They refer to re-usable, long lasting, medical equipment for use in the home that helps individuals to function on a daily basis.

This includes mechanical items such as wheelchairs, walkers, commodes and hand rails and electrical items like hospital bed, scooters, blood and glucose monitors, ventilators and nebulizers. DMEPOS is a Medicare-specific acronym that stands for Durable Medical Equipment, Prosthetics, Orthotics and Supplies.

From the consumer’s perspective. DMEPOS is essentially synonymous with DME. Assistive Technology (AT) and Assistive Devices are terms favored by the independent living community and refer to any item, electrical or mechanical that helps individuals with their activities of daily living. What is the difference between Assistive Technology vs. Durable Medical Equipment? Actually, there is very little difference.

The official definition according to the Assistive Technology Act of 1998 is as follows:“any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.”Home Medical Supplies Durable Medical Equipment should be differentiated from Home Medical Supplies. Supplies refer to single use items such as adult diapers and other incontinence supplies or diabetes test strips.

Read more about paying for home medical supplies. Prescriptions and DMEMost durable or home medical equipment can be purchased without a prescription, with oxygen being the notable exception. However, a prescription is extremely valuable in helping to get insurance to pay for an item. As an alternative to a prescription, individuals can prepare a Justification Statement of Medical Necessity which describes the condition, the need and why a specific brand and model item are necessary.

Who Determines What is Necessary A variety of different medical professionals have the expertise to assist individuals in determining what durable or home medical equipment is necessary.

These include Doctors, Nurse Practitioners, Physical and Occupational Therapists, Hospital Discharge Planners and most Home Care Agencies. Caregivers, because of their proximity to the individual in need of care, often have a good sense of what would be helpful but sometimes lack knowledge about the variety of options available.

It is also worth noting that sometimes older individuals will attempt to hide the extent of their need from their caregivers. Medical professionals may be better suited than family caregivers to recognize this tendency and discover the true extent of the individual’s needs.

As important as having the expertise to help in the selection of DME is having the authority to authorize paying for it. Insurance coverage usually requires a prescription or a “justification statement”. The higher degree of medical education held by the authorizing party, the more likely insurance will be to pay for the item. For some medical equipment, it is necessary to make home modifications. For example, older homes often require the widening of doorways to allow for wheelchairs or the addition of power outlets to accommodate for electrical equipment.

In these instances, the expertise of home contractors may be required to assess the extent of home modifications required and to provide a bid for the cost.

Learn more about paying for home modifications. Financial Assistance and Payment Options Typically, for any single item of durable medical equipment, there are multiple sources of payment. For example, Medicare will contribute, Medicare supplemental insurance may also help and an individual may pay a portion out-of-pocket as well. To minimize out-of-pocket costs, it is helpful to be aware of all the possible sources of funds that may be available to the elderly or disabled.

Did You Know? Seniors are eligibility to receive free, non-binding quotes for bathroom safety modifications. Get started now. Medicare and Private Insurance Medicare or other private health insurance cover the majority of spending on durable and home medical equipment. However, most insurance programs have co-pay requirements. Read about Medicare's DME policy. Medicaid and HCBS Waivers Medicaid will pay for home medical equipment, often covering 100% of the cost.

However, Medicaid is only for individuals with very low incomes and extremely limited assets. There are many different Medicaid programs and Medicaid Waiver programs and each one has different rules and benefits with regards to durable medical equipment.

For details and state specific HCBS Waiver information, please visit our Medicaid and DME page. Veterans Health Care and VA Insurance The Department of Veterans' Affairs, either through insurance, grants or other assistance programs, helps elderly veterans with the cost of medical equipment. Assistance may come in the form of paying Medicare’s co-payments, cash or actual equipment and supplies.

Assistance may come from a variety of sources within the VA such as: TRICARE for Life, CHAMPVA for Life, VD-HCBS or HISA and other grants. Read more about Veteran’s assistance for durable medical equipment. State Assistance Programs Separate from their Medicaid programs, every state provides some form of assistance to elderly and disabled individuals in need of home or durable medical equipment.

While some states have more robust programs than others, all states offer Assistive Technology Projects which help with the acquisition of DME and Protection and Advocacy Programs which primarily offer legal assistance to ensure insurance programs pay their part.

It addition, some states have assistance programs specifically designed to keep individuals off of Medicaid; some of these non-Medicaid programs help individuals by providing financial assistance for home medical equipment. Non-Profits and Foundations Both national foundations and local non-profits offer assistance programs for home and durable medical equipment. Some are condition-specific and others have financial requirements. Learn about specific non-profit and foundation assistance for home medical equipment. Other Options Tax Deductions Durable or home medical equipment are tax deductible under the Medical and Dental Expense Tax Credit.

One must be able to make a valid argument that the purchase of the item was a medical necessity. The easiest and strongest evidence for this argument is a written prescription or a “Certificate of Medical Necessity” from a doctor although this is not required.

Alternatively, the cost of durable medical equipment can be claimed using the Dependent Care Tax Credit if 1) one is caring for a family member or loved one who, for tax purposes, is considered a dependent and 2) the equipment is purchased to increase the care recipient’s ability to function independently so that the caregiver can work.

Reverse Mortgages In rare circumstances, getting a reverse mortgage may make sense to purchase medical equipment. For example, when the equipment is coupled with a significant home modification which will allow the individual to remain living at home for several years.

More about the pros and cons of reverse mortgages is available here. Life Settlements Selling a life insurance policy, called a life settlement can provide individuals with the option to receive large amounts of cash which can fund the purchase of expensive home medical equipment and to make any necessary home modifications, however this will only make good economic sense in some very limited situation.

More information. Injury Settlements If an elderly individual requires medical equipment because they were injured in an accident or fall, they may be eligible for compensation or reimbursement for the cost of the medical equipment and additional expenses. Learn more about receiving compensation for injuries and accidents. Long Term Care Insurance Most long-term care insurance policies work by paying out specific, agreed upon, daily dollar amounts directly to the insured individual or the designated payee.

For example, a policy may cover up to $150 / day for long term care. However, the definition of what long term care is varies with every policy. Fortunately, most policies consider the cost of medically necessary, durable or home medical equipment to be a covered long term care expense. Existing policy holders should check with their insurance providers to determine if durable medical equipment is covered.

. Prior to discussing Medicaid’s role in paying for durable medical equipment (DME), it is helpful to briefly explain how Medicaid works. Medicaid is an insurance program for Americans with low incomes and limited assets, primarily the elderly or disabled but also some adults and children.

Medicaidâs Coverage of Durable Medical Equipment

"Medicaid’s Coverage of Durable Medical Equipment Page Reviewed / Updated - Jul. 2017Other Help for Medical Equipment Find Financial Assistance for Care Help Finding Affordable Care Get Care Planning Assistance Table of Contents Medicaid Overview Place of Residence Impact Skilled Nursing Homes Medicaid at Home (HCBS)Consumer Direction (Cash and Counseling)Money Follows the Person Additional Resources Medicaid Overview There is not a single set of rules regarding Medicaid’s role in paying for durable medical equipment instead there are hundreds of different sets depending on one's state and Medicaid sub-program

Within each state, there are multiple Medicaid programs and several Home and Community Based Services Waivers. Eligibility rules and benefits are determined at the program or waiver level by each individual state. Therefore, there is not a single set of rules governing Medicaid’s role in paying for durable medical equipment instead there are 100’s of different sets of rules depending on the state and the Medicaid program in which one is enrolled.

Given there are many different sets of rules, generally speaking, Medicaid will pay for medical equipment when it is determined to be medically necessary, cost effective and meet their strict definition of what is durable medical equipment.

Most states define DME as “equipment that can withstand repeated use, is primarily used to serve a medical purpose, is appropriate for home use and is not useful to a person without an illness or injury.”Medicaid pays for the most basic equipment only not for ""extra features"".“Cost-effective” usually means that Medicaid will pay for the most basic level of equipment only.

For example, it may be clear that it is a medical necessity for an aging or disabled individual to have a powered wheelchair. However, Medicaid may determine that the individual only needs a less-expensive, rear-powered chair instead of a center-powered chair that has a tighter turning radius.

Medicaid and the Beneficiary’s Place of Residence Impact Despite there being hundreds of different Medicaid programs, most programs have similar processes for DME acquisition. These processes largely depend on the location in which the individual resides and intends to use the item.

The process and rules are different for those living at home vs. in a nursing home. It is worth noting that the definition of “at home” is more broadly interpreted by some states than others. At home can include living in a family member’s home, in independent living or in some cases even in assisted living communities.

Skilled Nursing Homes When an individual resides in a Medicaid approved nursing home, the process of acquiring durable medical equipment is largely invisible to the care recipient. The acquisition and approval process occurs behind the scenes and the individual is provided with the durable medical equipment item for which they have been approved.

Medicaid at Home (HCBS)Medicaid can be provided outside of nursing homes, when this occurs it is referred to as Home and Community Based Services or Waivers.

Individuals participating in a Medicaid Waiver program typically have a higher degree of personal involvement in the acquisition of DME than Medicaid Nursing Home residents. Individuals must obtain a medical justification letter for the durable medical equipment item from their doctor or therapist. They select a Medicaid-approved, DME supplier and provide them with the medical justification letter. The supplier completes a Prior Approval (PA) application and sends it to the state Medicaid office for approval.

The Medicaid office approves or denies the purchase and notifies both the individual and the supplier of their decision. If approved, the item is delivered by the supplier with the bill sent directly to Medicaid. If denied, the individual should receive the reason why and notification of the process to appeal the decision.

As one might assume, this process can be rather lengthy. For less expensive items, some seniors choose to purchase the item out-of-pocket rather than waiting months to gain approval. Buying durable medical equipment online is usually the least expensive route. Consumer Direction (Cash and Counseling)Some Medicaid Waivers and even some Medicaid State Plan benefits allow for Consumer Direction (sometimes referred to as Cash and Counseling), which means that the participants are allocated a budget and the flexibility to manage their own care providers and suppliers.

Individuals’ care needs are assessed and they are allocated the financial resources to pay for their care services, medical equipment and supplies.

Since these individuals are working within a defined budget and have the freedom to allocate it as they see fit, they have significant incentive to purchase inexpensive durable medical equipment and supplies to preserve their budget for other purposes.

Click here to learn more about Consumer Direction and Medicaid Waivers. Money Follows the Person This is special Medicaid program designed to help individuals that currently reside in nursing homes to return to their homes or to living in the community.

To make this possibly, the program will purchase some durable medical equipment to enable participants to live at home, such as hospital beds and wheelchair lifts. There are currently MFP Programs in forty-four states. The following six states do not have MFP programs: Alaska, Arizona, Florida, New Mexico, Utah and Wyoming. Read more about the Money Follows the Person Program. Readers should be aware that while forty-four states have MFP programs, the programs may be referred to using different names in different states.

Additional Resources Eligibility - More information regarding Medicaid eligibility is available here. Assistance Qualifying - A discussion of the public and private assistance options which help person to qualify for Medicaid is available here. List of Waivers - A complete list of Medicaid Waivers by state and their associated benefits is available here. "

Prior to a discussion about paying for durable medical equipment, it is helpful to have a clear understanding of what durable medical equipment is and to define some of the related terms and acronyms. Durable Medical Equipment (DME) as well as the terms, Home Medical Equipment (HME) and home healthcare equipment are used interchangeably. They refer to re-usable, long lasting, medical equipment for use in the home that helps individuals to function on a daily basis.

How to Pay for Home and Durable Medical Equipment: a Comprehensive Guide Page Reviewed / Updated - Jun.

2017Find Affordable Home Care Find Financial Help for Care Assistance for Wheelchairs Assistance for Walk In Tubs Assistance for Home Care Supplies Table of Contents Introduction Definitions and Terminology Prescriptions and DMEWho Determines What is Necessary Financial Assistance and Payment Options Medicare and Private Insurance Medicaid and HCBS Waivers Veterans Health Care and VA Insurance State Assistance Programs Non-Profits and Foundations Other Options Out-of-Pocket / Private Pay When Insurance Won't Pay Common Home Medical Equipment Costs Introduction As more Americans age in place, or remain living at home instead of moving into skilled nursing homes or assisted living residences, there has been an increased need for seniors to purchase home or durable medical equipment (DME).

Each year, approximately $100 Billion is spent on durable medical equipment in the U. S. Fifteen percent of which is paid for directly out-of-the-pocket of consumers.

It is the objective of this article to help individuals maximize the assistance they receive from their insurance coverage, find other financial assistance programs and minimize their out-of-pocket spending on DME. Definitions and Terminology

This includes mechanical items such as wheelchairs, walkers, commodes and hand rails and electrical items like hospital bed, scooters, blood and glucose monitors, ventilators and nebulizers. DMEPOS is a Medicare-specific acronym that stands for Durable Medical Equipment, Prosthetics, Orthotics and Supplies.

From the consumer’s perspective. DMEPOS is essentially synonymous with DME. Assistive Technology (AT) and Assistive Devices are terms favored by the independent living community and refer to any item, electrical or mechanical that helps individuals with their activities of daily living. What is the difference between Assistive Technology vs. Durable Medical Equipment? Actually, there is very little difference.

The official definition according to the Assistive Technology Act of 1998 is as follows:“any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.”Home Medical Supplies Durable Medical Equipment should be differentiated from Home Medical Supplies. Supplies refer to single use items such as adult diapers and other incontinence supplies or diabetes test strips.

Read more about paying for home medical supplies. Prescriptions and DMEMost durable or home medical equipment can be purchased without a prescription, with oxygen being the notable exception. However, a prescription is extremely valuable in helping to get insurance to pay for an item. As an alternative to a prescription, individuals can prepare a Justification Statement of Medical Necessity which describes the condition, the need and why a specific brand and model item are necessary.

Who Determines What is Necessary A variety of different medical professionals have the expertise to assist individuals in determining what durable or home medical equipment is necessary.

These include Doctors, Nurse Practitioners, Physical and Occupational Therapists, Hospital Discharge Planners and most Home Care Agencies. Caregivers, because of their proximity to the individual in need of care, often have a good sense of what would be helpful but sometimes lack knowledge about the variety of options available.

It is also worth noting that sometimes older individuals will attempt to hide the extent of their need from their caregivers. Medical professionals may be better suited than family caregivers to recognize this tendency and discover the true extent of the individual’s needs.

As important as having the expertise to help in the selection of DME is having the authority to authorize paying for it. Insurance coverage usually requires a prescription or a “justification statement”. The higher degree of medical education held by the authorizing party, the more likely insurance will be to pay for the item. For some medical equipment, it is necessary to make home modifications. For example, older homes often require the widening of doorways to allow for wheelchairs or the addition of power outlets to accommodate for electrical equipment.

In these instances, the expertise of home contractors may be required to assess the extent of home modifications required and to provide a bid for the cost.

Learn more about paying for home modifications. Financial Assistance and Payment Options Typically, for any single item of durable medical equipment, there are multiple sources of payment. For example, Medicare will contribute, Medicare supplemental insurance may also help and an individual may pay a portion out-of-pocket as well. To minimize out-of-pocket costs, it is helpful to be aware of all the possible sources of funds that may be available to the elderly or disabled.

Did You Know? Seniors are eligibility to receive free, non-binding quotes for bathroom safety modifications. Get started now. Medicare and Private Insurance Medicare or other private health insurance cover the majority of spending on durable and home medical equipment. However, most insurance programs have co-pay requirements. Read about Medicare's DME policy. Medicaid and HCBS Waivers Medicaid will pay for home medical equipment, often covering 100% of the cost.

However, Medicaid is only for individuals with very low incomes and extremely limited assets. There are many different Medicaid programs and Medicaid Waiver programs and each one has different rules and benefits with regards to durable medical equipment.

For details and state specific HCBS Waiver information, please visit our Medicaid and DME page. Veterans Health Care and VA Insurance The Department of Veterans' Affairs, either through insurance, grants or other assistance programs, helps elderly veterans with the cost of medical equipment. Assistance may come in the form of paying Medicare’s co-payments, cash or actual equipment and supplies.

Assistance may come from a variety of sources within the VA such as: TRICARE for Life, CHAMPVA for Life, VD-HCBS or HISA and other grants. Read more about Veteran’s assistance for durable medical equipment. State Assistance Programs Separate from their Medicaid programs, every state provides some form of assistance to elderly and disabled individuals in need of home or durable medical equipment.

While some states have more robust programs than others, all states offer Assistive Technology Projects which help with the acquisition of DME and Protection and Advocacy Programs which primarily offer legal assistance to ensure insurance programs pay their part.

It addition, some states have assistance programs specifically designed to keep individuals off of Medicaid; some of these non-Medicaid programs help individuals by providing financial assistance for home medical equipment. Non-Profits and Foundations Both national foundations and local non-profits offer assistance programs for home and durable medical equipment. Some are condition-specific and others have financial requirements. Learn about specific non-profit and foundation assistance for home medical equipment. Other Options Tax Deductions Durable or home medical equipment are tax deductible under the Medical and Dental Expense Tax Credit.

One must be able to make a valid argument that the purchase of the item was a medical necessity. The easiest and strongest evidence for this argument is a written prescription or a “Certificate of Medical Necessity” from a doctor although this is not required.

Alternatively, the cost of durable medical equipment can be claimed using the Dependent Care Tax Credit if 1) one is caring for a family member or loved one who, for tax purposes, is considered a dependent and 2) the equipment is purchased to increase the care recipient’s ability to function independently so that the caregiver can work.

Reverse Mortgages In rare circumstances, getting a reverse mortgage may make sense to purchase medical equipment. For example, when the equipment is coupled with a significant home modification which will allow the individual to remain living at home for several years.

More about the pros and cons of reverse mortgages is available here. Life Settlements Selling a life insurance policy, called a life settlement can provide individuals with the option to receive large amounts of cash which can fund the purchase of expensive home medical equipment and to make any necessary home modifications, however this will only make good economic sense in some very limited situation.

More information. Injury Settlements If an elderly individual requires medical equipment because they were injured in an accident or fall, they may be eligible for compensation or reimbursement for the cost of the medical equipment and additional expenses. Learn more about receiving compensation for injuries and accidents. Long Term Care Insurance Most long-term care insurance policies work by paying out specific, agreed upon, daily dollar amounts directly to the insured individual or the designated payee.

For example, a policy may cover up to $150 / day for long term care. However, the definition of what long term care is varies with every policy. Fortunately, most policies consider the cost of medically necessary, durable or home medical equipment to be a covered long term care expense. Existing policy holders should check with their insurance providers to determine if durable medical equipment is covered.

Durable medical equipment may be covered when the following criteria are met: The equipment provides therapeutic benefit to a patient in need because of a certain medical condition or illness The DME is prescribed by a licensed provider

What is Durable Medical Equipment (DME)?

What is Durable Medical Equipment (DME)? Durable Medical Equipment is any equipment that provides benefits to a patient in need because of certain medical conditions or illnesses.

DME consists of items which: Are primarily and customarily used to serve a medial purpose Are not useful to a person in the absence of illness or injury A re ordered or prescribed by a physician A re reusable Can stand repeated use A re appropriate for use in the home Boot Knee Caddy (Scooter) Arm Sling Game Ready DME at TRIADME is provided at TRIA by Park Nicollet Health Products.

Our fitters are available Monday through Friday 8:30 a.m. – 4:00 p.m. to assist you with fittings. Rentals available at TRIA include: Knee caddies (scooters)Game Readies Insurance

Questions For questions about Durable Medical Equipment, call 952-806-5467

. The providers telephone number is (281)-332-3405 . This healthcare provider has their gender reported as 'not applicable'. Speciality : Durable Medical Equipment and Medical Supplies - More people are using Lab Draw to locate durable medical equipment and medical supplies in their localities. T...

A & T MEDICAL SALES AND RENTAL, INC. -Durable Medical Equipment and Medical Supplies

A & T MEDICAL SALES AND RENTAL, INC. -Durable Medical Equipment and Medical Supplies No review Durable Medical Equipment and Medical Supplies17220 HIGHWAY 3 WEBSTER, TX 77598 Phone: (281)-332-3405 NPI Number: 1407821705 Updated: 06/19/2008Claim this page to add website here Doctor Details A & T MEDICAL SALES AND RENTAL, INC.'s specialty is listed as Durable Medical Equipment and Medical Supplies.

The practice business address for this provider is in the wonderful city of WEBSTER, in the state of TX. This healthcare provider is listed as practicing at this street address: 17220 HIGHWAY 3

Read More >>Map To A & T MEDICAL SALES AND RENTAL, INC. Rating and reviews -No review BE THE FIRST TO WRITE A REVIEW!

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les A fixed dollar amount that must be paid by an insured patient, normally during an annual period, before the insurance company pays the cost of medical services. Diabetes Education Includes formal training on prevention and management of diabetes, with scheduled follow-up and screening. Durable medical equipment

Diabetes Health Coverage: State Laws and Programs

"Diabetes Health Coverage: State Laws and Programs1/10/2016Table of Contents What This Report Covers Introduction and Overview Obesity and Diabetes State Insurance and Medicaid Coverage Requirements and Programs Additional Resources Contact Health Program This is a policymaker and consumer guide to state insurance mandated coverage, Medicaid coverage and state-sponsored diabetes programs. It was published 2011and updated material was added January 2016What this Report Covers All state law diabetes mandates and minimum coverage requirements for state-regulated health insurance policies.

The tables include the enacted state laws passed since the first mandates in California (1981) and New York (1993).

Use links below to go directly to state-based information: Alabama 2016, Alaska 2016, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia 2016, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi 2016, Missouri 2016, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, District of Columbia, Puerto Rico, U. S. Virgin Islands, and Guam.

State Medicaid diabetes coverage terms and conditions. All Children's Health Insurance Program (CHIP) diabetes coverage.

Contact information and an overview of federal funding provided by the Centers for Disease Control and Prevention (CDC) to state-sponsored diabetes prevention and control programs (DPCPs). DPCPs represent the front line in battling diabetes in most states. An overview of other state activities and initiatives, such as creation of diabetes coordinator positions in the executive branch to fight diabetes.

Federal Health Reform . The federal Affordable Care Act (ACA) signed March 2010, has led to changed and expanded coverage termed "" Essential Health Benefits.

""Newly Released: NCSL Survey: Diabetes Drug coverage: A new survey of 2016 Insurance Plans in 50 states, examining 1) patient access to the scores of diabetes drug treatments and 2) results in the 46 states with laws mandating or offering diabetes coverage. NCSL original research, published summer 2016. [Read the report]December 2015: "" Diabetes: Addressing the Costs; A 50-State Budget Survey for FY 2014 .""

NCSL released its latest diabetes report, taking a closer look at programs and budget appropriations that play a role in control and prevention of diabetes, the chronic disease affecting 29 million Americans.

For 2014 budgets, 20 states appropriated some funding for diabetes in their budgets; while all 50-states received some CDC federal funds for chronic disease programs. The report is especially timely for the 30 plus states that begin state budget deliberations this January. Download the 12-page Diabetes Survey PDF here Introduction and Overview Nearly 29.1 million people in the United States have diabetes, equal to 9.3 percent of the total population as of 2014.

An estimated additional 86 million adults age 20 and older have “pre-diabetes,” a condition that still can be halted. According to the Centers for Disease Control and Prevention (CDC), about 1.9 million people aged 20 years or older were newly diagnosed with diabetes in 2010 in the United States.

The CDC data report released in 2008 confirmed that diabetes is the largest and fastest-growing chronic disease in the nation. Diabetes is characterized by a condition where the body does not produce or properly use insulin. Insulin is necessary to covert sugar, starches and other foods into energy for living. Among the types of diabetes,Type 1 diabetes is usually diagnosed in children and young adults and was previously known as juvenile diabetes.

Insulin shots are the only way to keep blood glucose levels down in Type 1 diabetes sufferers. Type 2 diabetes, which is the most common form of diabetes, causes the body to not produce enough insulin or causes the cells to ignore the insulin.

Gestational diabetes occurs when pregnant women who have never had diabetes before have high blood sugar (glucose) levels during pregnancy. Gestational diabetes requires pregnant women to manage their condition during pregnancy to deliver a healthy child. The condition is temporary and usually reverses after the child's birth. However, women who develop the condition are at a higher risk of developing diabetes later in life.

Pre-Diabetes occurs an individual develops type 2 diabetes, he or she almost always has ""pre-diabetes."" In this condition, blood glucose levels are higher than normal, but not yet high enough to be diagnosed as diabetes.

Fifty-seven million people in the United States have pre-diabetes. Research shows that, when individuals with pre-diabetes take action to manage their blood glucose, they can delay or prevent type 2 diabetes from developing. A leading cause of blindness, kidney disease, heart disease and amputations, diabetes also claims the lives of more than 193,000 Americans each year. According to the CDC, it was the country's seventh leading cause of death by disease in 2007. Diabetes is treatable.

Although there is no ""cure"" various treatments allow most diabetics to live relatively stable, normal lives. Early screening, diagnosis and treatment also prevent or reduce the more serious consequences of the disease — emergency room visits, hospitalization, loss of sight, loss of limbs.

Once diagnosed, diabetes requires self-management, including testing and monitoring blood glucose levels. Because treatment requires patient education, special equipment and supplies, it can become costly especially when it is not covered by health insurance.

The Role of State Laws States have recognized the major effects diabetes plays, both in its impact on patients and on society. As of mid-2016, 46 states and the District of Columbia have some law that requires health insurance policy coverage for diabetes treatment. Laws in Mississippi and Missouri require only that insurers offer coverage, but not necessarily include the coverage in all active policies.

Most states require coverage for both direct treatment and for diabetes equipment and supplies that are often used by the patient at home. The four states that do not have a mandate or insurance requirement are Alabama, Idaho, North Dakota and Ohio. State tables include the enacted state laws passed since the first California mandates in 1981 and New York's in 1993, through early 2016.

For more information about diabetes legislation, visit NCSL's Diabetes - State Legislation Overview. Economic Costs of Diabetes in the United States Diabetes has become a costly chronic condition in the United States. According to the2015 study by the Health Care Cost Institute, medical costs and productivity loss attributable to diabetes were estimated to be $245 billion in 2012.

By comparison, the estimated total cost of diabetes in 2007 was $174 billion. Includes $116 billion in excess medical expenditures and $58 billion in reduced national productivity$27 billion for care to directly treat diabetes$58 billion to treat the portion of diabetes-related chronic complications that are attributed to diabetes$31 billion in excess general medical costs By 2012 the total cost of diabetes had increased to $245 billion ,meaning that the disease’s toll on the economy has increased by more than 40 percent since 2007, according to a recent report from the American Diabetes Association.

A study commissioned by the National Changing Diabetes Program added to the existing estimate the costs for undiagnosed diabetes, pre-diabetes and gestational diabetes to bring the total to $218 billion in 2007. Furthermore, by 2025, the number of people with diabetes is expected to double, placing increased demands on the healthcare system and creating opportunities for more integrated and innovative disease management.

For more information about state and CDC diabetes funding, visit NCSL's Diabetes in State Budgets: A 50-State Survey for Fiscal Year 2011. Obesity and Diabetes Obesity in persons with diabetes is associated with poorer control of blood glucose levels, blood pressure and cholesterol, placing persons with diabetes at higher risk for both cardiovascular and microvascular disease.

A 2002 CDC study of the prevalence of obesity among individuals diagnosed with diabetes showed that 57.9% of non-Hispanic whites diagnosed with diabetes were also obese.

This figure was 63.0% for non-Hispanic blacks, and 59.5% for Mexican Americans. Weight management, through healthy eating and physical activity, can help reduce the number of persons at risk for diabetes and reduce the risk for complications and premature mortality among those who already have diabetes.

NCSL had a 2009 special project on obesity, available at http://www.ncsl.org/Default.aspx?tabid=14339Diabetes and Native Americans Diabetes affects American Indians/Alaskan Natives (AI/ANs) disproportionately compared with other racial/ethnic populations and has been increasing in prevalence. The CDC estimates that prevalence of diabetes for AI/AN adults is more than twice that of U. S. adults overall.

A CDC study in 2003 showed about 16.5% of American Indians and Alaska Natives aged 20 years or older who received care from the Indian Health Service (IHS) in 2003 had diabetes. The rates of diabetes vary within this population with diabetes being diagnosed at 6% among Alaska Native adults and 29.3% among Native American adults in Southern Arizona. The U. S. Congress established the Special Diabetes Program for Indians (SDPI) in 1997. The SDPI provides funding for diabetes treatment and prevention services at 399 IHS, Tribal and Urban Indian health programs in the 12 IHS areas in 35 states across the United States.

IHS has used these funds to establish approximately 350 new diabetes programs in AI/AN communities.

In 1998, CDC and IHS established the National Diabetes Prevention Center in Gallup, New Mexico, to provide guidance and technical support to AI/AN communities throughout the United States and to develop, evaluate, and disseminate culturally appropriate interventions. More information on the work of IHS with regard to diabetes treatment can be found online at: http://www.ihs.gov/Medical Programs/diabetes/ . Some states with sizeable Native American populations supplement IHS programs with additional resources and programs.

State and Federal Requirements for Coverage Laws in 46 states and the District of Columbia require private market health insurance coverage or offerings for people enrolled in a health plan and diagnosed with diabetes. Most individuals with diabetes had coverage through private insurance (39 percent) or Medicare (44 percent). Eleven percent of diagnosed diabetics under the age of 65 were uninsured and most likely to be from low income backgrounds.

Diabetics covered in the private insurance market generally belong to employer-sponsored group health plans or individual health plans. Employer-sponsored group health plans are the most popular because coverage is subsidized and often offer higher protection.

Those under age 65 whose job or family member's job does not offer such coverage usually must rely on the ""individual insurance market."" They may have difficulties finding affordable plans that will accept them, especially if they have a pre-existing chronic disease such as diabetes.

In some circumstances where individuals may not be covered, or may not be fully covered, for diabetes treatment despite living in a ""mandate"" state.

These include enrollment in: 1) a ""high-deductible health plan (HDHP) often combined with a ""health savings account"" (HSA) in which the enrollee must pay 100 percent of treatment costs until he or she reaches a ""deductible"" level -- often an amount of at least $1,150 annually, and in some cases as high as $10,000 annually.

2) special ""mandate light"" or mandate-exception policies aimed at special populations such as workers for small employers. 3) Bare bones or ""capped benefit"" insurance policies that may limit coverage to a set dollar amount per year.

State Roles Limited by ERISA. State health insurance laws apply to about 45 percent of all private market health policies - those ""fully insured plans"" in which mostly small and medium sized businesses pay premiums. Federal ERISA law applies to the other 55 percent of policies that are sometimes called ""self-insured plans.""

Some 73 million American workers and their dependents were covered by self insured plans in 2007 - that is, policies in which the employer assumes the financial risk for providing health care benefits to its employees, rather than buying insurance. There is no federal law mandate for diabetes insurance coverage. (Source: Employee Benefit Research Institute, February 2008).

Medicare is the federal program that covers both the majority of those over age 65 and people with disabilities.

A summary follows of diabetes-specific benefits for relevant Medicare components. Medicare Part B, an optional service with a modest monthly premium (set at $93 per month in 2009), provides coverage for physician visits, diabetes screening, diabetes self-management training and nutrition counseling services, lab testing, diabetes glucose testing supplies, and insulin pumps and associated supplies. Medicare information describing available diabetes coverage is online at http://www.medicare.gov/Publications/Search/Results.asp?

Pub ID=11022&Type=Pub ID&Language=English. For people with Medicare Part B who are at risk for getting diabetes, Medicare covers a screening blood sugar test to check for diabetes. Medicare considers an individual at risk if he or she has any of the following: high blood pressure, history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar.

Other risk factors may also qualify enrollees for this test and based on the results, they may be eligible for up to two screenings each year. Medicare Part D is a separate optional coverage that provides a relatively consistent level of prescription drug coverage.

Begun in 2006, the plans provide coverage for prescription drugs, including insulin, insulin pens and syringes. Part D Prescription Drug Plans (PDPs) are provided by commercial insurers and are allowed considerable variation in their Medicare enrollee charges. The ""base beneficiary premium"" for 2009 is $30.36 per month according to the Centers for Medicare and Medicaid Services.

In practice, premiums vary significantly from one Part D plan to another. The Part D benefits may also be subject to a coverage gap or ""donut hole"" for any prescription drug purchases between $2,700 and $6,154; the program has a maximum out-of-pocket enrollee share of $3,453.75 in 2009. Approximately 20 states provide some financial help to certain low and moderate income residents enrolled in this part of the Medicare program. NCSL has a web-based report with details on the states that provide some subsidies for Part D prescription drug policies.

The NCSL report is available at http://www.ncsl.org/default.aspx?tabid=14334. Low-income Medicare enrollees who also are eligible for Medicaid, known as ""dually eligible,"" often are entitled to significantly smaller out-of-pocket payments. The Medicare Program federal website has specific information for diabetes treatment, available at http://www.medicare.gov/Publications/Search/Results.asp? Pub ID=11022&Type=Pub ID&Language=English. Medicaid covers the health care needs for qualified low-income people and those who have few resources.

There are special expanded eligibility terms for pregnant women. Medicaid is jointly funded by the federal and state governments; covered populations and benefits vary among states. As a condition for receipt of federal funding, states must provide certain services, such as in- and out-patient care, doctor visits and long-term care. While services such as prescription drugs are optional under federal law all states and territories have chosen to include them.

Other details of benefits such as prescribed insulin, disposable needles, syringes, monitors and blood glucose strips are determined by each state's Medicaid policy and are listed by state. The Children's Health Insurance Program (CHIP) formerly known as SCHIP (the State Children's Health Insurance Program) - has become the nation's primary source of coverage for uninsured children who do not qualify under Medicaid.

In 2008, 7.4 million children received health coverage through CHIP. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) passed in April 2009 both extended and expanded CHIP through September 2013. The federal government covers about 70 percent of the programs' cost nationwide with state governments picking up the rest of the cost.

Diabetes treatment and management is available to children enrolled through the CHIP program. Diabetes treatment options are comparable to those available under Medicaid in most states, although patients may be responsible for higher payments and care defined as diabetes education services. Other Diabetes Programs and Activities State-Based Diabetes Prevention and Control Programs are programs supported by the Centers for Disease Control and Prevention (CDC).

The CDC provides financial assistance and support to states to improve health care services for preventing, detecting and treating diabetes and its related complications. This assistance is provided in the form of grants to State Diabetes Prevention and Control Programs (DPCPs) that typically are housed within departments that oversee health programs in a given state. DPCPs often represent the front-line of efforts to prevent, manage and control the reach of diabetes.

States must apply to CDC annually for available DPCP funds Appropriations made available to CDC in FY 2009 provided $27,444,988 in grants to all DPCPs in the United States and Puerto Rico.

About another $900,000 was made available to the territories and the U. S. Virgin Islands for FY 2009. The FY 2009 grants amounted to a 4.3 percent reduction in funds available during FY 2008. This reduction occurred due to limited funding during a time when CDC data documented that the number of people continued to grow nationwide.

Beginning in FY 2009, the CDC finalized new five-year cooperative agreements with all 50 states, the District of Columbia, Puerto Rico and the territories for DPCPs. These agreements established a new funding formula for DPCP grants. This formula weights grant applications based on the total population living with diabetes (60 percent weight) and the percentage of people with diabetes (40 percent weight) within a state or territory.

According to the CDC, distributing funds under the new formula allows greater equity and distribution of money to states and territories that have higher percentages of people living with diabetes.

The range of grants available to states and territories in FY 2009 was between $202,000 and $1,043,000. The limited funding appropriated, coupled with the new distribution formula for grants, led most states to experience a reduction in grants provided to DPCPs in FY 2009.

State governments are required to supplement DPCP grants by contributing at least $1 for every $4 provided. An early 2009 assessment found that most states and territories do not provide separate funding for this purpose.

Although several states - including Kentucky, Michigan, New Mexico, New York and Texas - provide significant financial resources to supplement DPCP grants, state assistance to the programs is less certain due to the current budget crisis. State Diabetes Coordinators were created to bring greater efficiencies across state departments by aligning resources and objectives, several states have considered creating a state diabetes coordinator.

Tennessee, under the direction of Governor Bredesen, the Legislature and the state Health Department Commissioner Susan Cooper, created the nation's first state-wide Diabetes Coordinator. The Tennessee legislation to create a state diabetes coordinator within the department of Health was enacted into law on 5/12/08 (SB 1252).

Other state level proposals include a bill introduced in Georgia in 2007 by Senator Balfour (SB 505), now signed into law as Act 102 in May 2009; and bills filed in New York by Assembly member Ortiz (A 6949) and Senator Montgomery (S 5272) in May 2009.

Federal legislation to create a National Diabetes Coordinator was introduced in Congress in 2008 (HR 4836). Figure 1. State Diabetes Coverage Requirements within Private Insurance Map data updated August 2015 based on NCSL research.

Coverage for Supplies and Equipment (may include training/education - see state tables for details)How Diabetes Mandates are Worded For diabetics, coverage of prescription medications - including insulin, medical supplies such as insulin syringes, and equipment such as blood glucose monitors - is essential to medical treatment. Under the Texas Insurance Code, for example, equipment includes blood glucose monitors, including noninvasive glucose monitors and glucose monitors designed to be used by the blind; insulin pumps and associated equipment; insulin infusion devices; and podiatry appliances to prevent complications associated with diabetes.

Supplies include test strips for blood glucose monitors; visual reading and urine test strips; lancets and lancet devices; insulin and insulin analogs; injection aids; syringes; prescriptive and nonprescriptive oral agents to control blood sugar levels; and glucagon emergency kits. In most state legislatures, however the two terms are used interchangeably and may not be defined.

Some states have issued regulatory guidelines further defining the terms. Coverage for Artificial Limbs (Prosthetic Devices)Approximately 2 million Americans have lost a limb, and many cases are attributed to complications of diabetes that lead to amputation.

As of December 2008, there are 14 states that have passed legislation pertaining to the coverage of prosthetic / orthotic devices — California (must offer, 2006), Colorado (2000), Connecticut (1987), Indiana (2008), Louisiana (2008), Maine (2003), Maryland (1999), Massachusetts (2006), Michigan (1986), New Hampshire (2004), New Jersey (2008), Oregon (2007), Rhode Island (2006), and Vermont (2008) — .

In 13 states the legislation requires an insurer to cover prosthetic devices under its policy, as it would any other medical procedure; in California insurers must offer at least one policy that includes orthotics/prosthetics but other policies can exclude them. Diabetes Management and Treatment Products Examples of brand-name and generic products prescribed and used for diabetes management and treatment.

SUPPLIES/EQUIPMENT EXAMPLES OF WIDELY USED BRANDS AND TYPESInsulin Syringes BD Ultrafine, Levemir®, Monoject, Novo Fine®, Ulticare, Uni Fine, Ulti Gaurd Insulin Apidra, Humulin, Lantuo, Lente, Levemin, Novolog, Novolin, NPH Insulin, Regular Iletin, Regular Insulin, Velosulin Insulin Pumps Animas, Deltec, Medtronic Blood Glucose Test Meters and Test Strips Abbott Freestyle®, Abbott Flash, Accu-Chek Compact®, Ascensia Elite, Ascencia Breeze, Ascensia Contour, Lifescan One-Touch©, Prestige Injectable Medication Byetta (Exenatide) injection and Symlin (Pramlintide Acetate) injection, Victoza (l Liraglutide- r DNA origin) injection Oral Medications Acarbose, Avandia, Chlorpropamide, Diabinese, Glipizide, Glucophage, Glucotrol, Gylset, Meglitol, Metformin, Prandin, Precose, Repaglinide, Rosiglitazone (These drugs act in different ways to lower blood glucose levels and may be prescribed in combination with other medication. )Key/ Definitions TERM DEFINITIONBlanket Health Insurance Policy Normally, a health insurance policy that covers a group of individuals such as employees of an organization, students at a school, members or a labor union, etc. Copayment A fixed dollar amount that must be paid by an insured individual each time a medical service is accessed before the insurance company provides its share of the medical expenses. Deductib

les A fixed dollar amount that must be paid by an insured patient, normally during an annual period, before the insurance company pays the cost of medical services. Diabetes Education Includes formal training on prevention and management of diabetes, with scheduled follow-up and screening. Durable medical equipment

Term used to describe certain insurance related benefits such as wheelchairs, oxygen tent, hospital beds, etc. However, the term generally includes insulin pumps, insulin pump supplies, blood glucose meters, blood glucose meter test strips and other day-to-day diabetes management needs. Federal Poverty Level (FPL)An eligibility benchmark, officially the ""Federal Poverty Guideline,"" set annually by the U. S. Department of Health and Human Services and used by many states and federal programs to determine if residents are eligible to be enrolled, based on annual income.

Maximum eligibility levels often are set at a percentage of ""FPL"", such as 150 percent or 200 percent.

For 2009, the official FPL was $10,830 for an individual, $14,570 for a two person household and $3,740 for each additional household member. Gestational Diabetes Pregnant women who have never had diabetes before but who have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes.

Gestational diabetes affects about 4% of all pregnant women - about 135,000 cases of gestational diabetes in the United States each year. Glycemic contro l Refers to the typical and changing levels of blood sugar in a person with diabetes. Interdialytic parenteral nutrition Nutrition provided to diabetes patients during dialysis. Lancing and Lancet Devices A blood-sampling device used by diabetics to draw blood from a fingertip or other area to monitor blood glucose levels.

Medical Nutrition Therapy Nutritional diagnostic, therapeutic, and counseling services provided by a registered dietitian. Medigap Refers to the various private supplemental health insurance plans sold to Medicare beneficiaries that provide coverage for medical expenses not or only partially covered by federal Medicare. National Diabetes Educational Program (NDEP)NDEP is jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention with the support of more than 200 partner organizations.

NDEP works to translate and spread the latest science on diabetes to the public. Orthotic Insert or Orthotics Refers to procedures dealing with the support and bracing of weak or ineffective joints and muscles.

For people with diabetes this can include specially designed shoes aimed to reduce the risk of a lower leg amputation to more involved prosthetic devices. Subscription Contracts A contract between a corporation and its subscribers to provide certain medical services.

State Insurance and Medicaid Coverage Requirements and Programs Alabama Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance4,627,8512,50049,000137,00071,00047,000307,5004,021,000State Laws and Regulations No applicable statute. Alabama is one of four states that does not have a mandate or insurance requirement specific to diabetes coverage.

Insurance Policies Required to Provide Coverage N/APeople Covered by Insurance Mandates N/ABenefits Required Medication: No N/AEquipment and Supplies: No N/AEducation: No N/AServices: No N/ACopayments/Deductibles N/ASpecial Features and Issues N/AStatute Web Link N/APublic Programs Medicaid CHIPPrescribed Insulin: Covered* Covered**Disposable Needles: Covered Covered**Syringe Combinations: Covered Covered**Blood Glucose Strips: Covered Covered**Notes: * Covered with restrictions: prescribed insulin and syringe combinations used for insulin (on preferred drug lists (PDL) and maximum units apply) and intradialytic parenteral nutrition (certification of medical necessity on script).

** Requires a copay depending on fee group (based on fee group according to FPL); no fee for Native American patients.

Diabetes Prevention and Control Programs Alabama Diabetes Prevention and Control Program, Bureau of Health Promotion & Chronic Disease http://www.adph.org/diabetes/Alaska Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance683,4784003,00011,0003,0002,00020,400552,000State Laws and Regulations Alaska statute: Alaska ST §21.42.390 , Date enacted: 2000.

Insurance Policies Required to Provide Coverage All health care insurance plans must include coverage for outpatient self-management training and education and medical nutrition therapy. A health care insurance plan that includes coverage for pharmacy services must provide coverage for the cost of treating diabetes, including medication, equipment and supplies.

People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Not specified. Education: Yes Medical nutrition therapy included, if diabetes treatment is prescribed by a health care provider.

Services: Yes Coverage for outpatient self-management training. Copayments/Deductibles Coverage is subject to standard policy provisions applicable to other benefits, including deductible or copayment provisions. Special Features and Issues Coverage for the cost of diabetes outpatient self-management training or education and for the cost of medical nutrition therapy is required only if provided by a health care provider trained in diabetes treatment of diabetes.

Alaska requires coverage for medical nutritional therapy, equipment and supplies only when the contract or insurance policy has prescription drug coverage. Statute Web Linkhttp://www.legis.state.ak.us/cgi-bin/folioisa.dll/stattx03/query=*/doc/%7b@9330%7d?

Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: **Covered as durable medical equipment.

Diabetes Prevention and Control Programs Alaska Diabetes Prevention and Control Program http://www.hss.state.ak.us/dph/chronic/diabetes/default.htm Arizona Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance6,338,755 4,000 66,000 108,000 71,000 48,000 299,000 5,204,000State Laws and Regulations Arizona statute: ST §20-2325: Diabetes equipment, supplies; ST §20-826, Subscription contracts; ST §20-1057 : Evidence of coverage by health care services organizations, renewability; ST §20-1342: Scope and format of policy; ST §20-1402: Provisions of group disability policies; ST §20-1404: Blanket disability insurance, Date enacted: 1998.

Insurance Policies Required to Provide Coverage Hospital, medical, dental and optometric service corporation contracts; health care service organizations; disability insurance group and blanket disability insurance plans must include coverage for diabetes equipment and supplies. People Covered by Insurance Mandates Patients with diabetes; type of diabetes not specified. Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Blood glucose monitors. Blood glucose monitors for the legally blind.

Test strips for glucose monitors and visual reading and urine testing strips. Insulin preparations and glucagon. Insulin cartridges. Drawing up devices and monitors for the visually impaired. Injection aids. Insulin cartridges for the legally blind. Syringes and lancets including automatic lancing devices. Prescribed oral agents for controlling blood sugar that are included on the plan formulary. To the extent coverage is required under Medicare, podiatry appliances for prevention of complications associated with diabetes.

Any other device, medication, equipment or supply for which coverage is required under Medicare from and after Jan 1, 1999. The coverage required in this paragraph is effective six months after the coverage is required under Medicare.

Education: No N/AServices: No N/ACopayments/Deductibles Nothing prohibits a group disability insurer from imposing deductibles, coinsurance or other cost sharing in relation to benefits for equipment or supplies to treat diabetes.

Special Features and Issues Arizona requires coverage of equipment and supplies only when the insurance policy covers expenses incurred to treat diabetes.

Statute Web Linkhttp://www.azleg.gov/Format Document.asp?in Doc=/ars/20/02325.htm&Title=20&Doc Type=ARSPublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Arizona Diabetes Control & Prevention Coordinator, Arizona Department of Health Services http://www.azdiabetes.gov/Arkansas Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance2,834,7971,60024,00077,00032,00023,000157,6002,354,000State Laws and Regulations Arkansas statutes: ST §23-79-601: Definitions; ST §23-79-602: Diabetes self-management training licensed providers; prescription by physician; ST §23-79-603: Requirements; ST §23-79-604: Exclusions; ST §23-79-605: Regulations; ST §23-79-606: Applicability – Delivery within state; ST §23-79-607: Applicability – Exceptions.

Date effective: Aug 1, 1997. Insurance Policies Required to Provide Coverage""Health insurance policy” means a group insurance policy, contract or plan or an individual policy, contract or plan that provides medical coverage on an expense incurred, service or prepaid risk-sharing basis. People Covered by Insurance Mandates Type I diabetes Type II diabetes Gestational diabetes Benefits Required Medication: N/ANot mentioned.

Equipment and Supplies: Yes Blood glucose monitors, which include all commercially available blood glucose monitors designed for patient use and for those who have been diagnosed with diabetes. Blood glucose monitors for the legally blind, which include all commercially available blood glucose monitors designed for patient use with adaptive devices and for those who are legally blind and have been diagnosed with diabetes.

Test strips for glucose monitors, which include all test strips approved by the Federal Food and Drug Administration, glucose control solutions, lancet devices, and lancets for monitoring glycemic control. Visual reading and urine testing strips, which include visual reading strips for glucose, urine testing strips for ketones, or urine test strips for both glucose and ketones.

Urine test strips for glucose only are not acceptable as the sole method of monitoring. Insulin, which includes all commercially available insulin preparations including insulin analog preparations available in either vial or cartridge. Injection aids, which include devices used to assist with insulin injection. Syringes, which include insulin syringes, pen-like insulin injection devices and pen needles for pen-like insulin injection devices.

Insulin pumps as prescribed by the physician and appurtenances thereto, which include insulin infusion pumps and supplies such as skin preparations, adhesive supplies, infusion sets, cartridges, batteries and other disposable supplies needed to maintain insulin pump therapy. These include durable and disposable devices used to assist in the injection of insulin. Oral agents for controlling the blood sugar level, which are prescription drugs.

Podiatric appliances to prevent of complications associated with diabetes, which include therapeutic molded or depth-inlay shoes, replacement inserts, preventive devices, and shoe modifications for prevention and treatment. Glucagon emergency kits and injectable glucagon. Education: Yes Medical nutritional therapy included. Services: Yes Self-management training. Copayments/Deductibles Deductibles, coinsurance, other patient cost-sharing amounts or out-of-pocket limits or prior authorization or other utilization review requirements or processes will remain consistent with those established for other services covered by a given health insurance policy.

Special Features and Issues N/AStatute Web Linkhttp://www.arkansas.gov/asbp/pdf/lawbook03/Stat_Insurance_Policies.pdf Public Programs Medicaid CHIPPrescribed Insulin: Covered with restrictions Covered Disposable Needles: Covered with restrictions Covered Syringe Combinations: Covered with restrictions Not covered Blood Glucose Strips: Not Covered Covered Notes: N/ADiabetes Prevention and Control Programs Arkansas, Diabetes Control Program, Arkansas Department of Health Visit the webiste here.

California Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance36,553,21521,000 337,000 824,000 396,000 312,000 1,889,000 29,682,000State Laws and Regulations California Statutes: HLTH & S §1367.51: Diabetes supplies and equipment; INS §10176.6: Insurance Coverage; INS §10176.61; INS §10177.7. Date enacted: Sept. 30, 2000. Insurance Policies Required to Provide Coverage Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, delivered or renewed on or after Jan 1, 2000, and that covers hospital, medical or surgical expenses. People Covered by Insurance Mandates Insulin-using diabetes Non-insulin-using diabetes Gestational diabetes Benefits Required Medication: Yes Insulin.

Prescriptive medications to treat diabetes. Glucagon. Equipment and Supplies: Yes Blood glucose monitors and blood glucose testing strips. Blood glucose monitors designed to assist the visually impaired. Insulin pumps and all related necessary supplies. Ketone urine testing strips. Lancets and lancet puncture devices. Pen delivery systems to administer insulin.

Podiatric devices to prevent or treat diabetes-related complications. Insulin syringes. Visual aids, excluding eyewear, to help the visually impaired with proper dosing of insulin. Education: Yes Medical nutritional therapy included. Services: Yes Diabetes outpatient self-management training. Benefits shall include, but not be limited to, instruction that will enable diabetic patients and their families to gain an understanding of the diabetic disease process, and the daily management of diabetic therapy, in order to avoid frequent hospitalization and complications.

Coverage for Amputees: Yes, offer Insurers must offer at least one policy with this choice; See below under ""Special features and issues"" for more detailed information.

Copayments/Deductibles The copayments and deductibles for the benefits specified in “equipment” and “medication” shall not exceed those established for similar benefits within the given plan. The copayments for the benefits specified in “services” shall not exceed those established for physician office visits by the plan.

Special Features and Issues Coverage for amputees: 1367.18: Every health care service plan, except a specialized health care service plan, that covers hospital, medical or surgical expenses on a group basis shall offer coverage for orthotic and prosthetic devices and services.

Statute Web Linkhttp://www.leginfo.ca.gov/pub/99-00/bill/sen/sb_2051-2100/sb_2094_bill_20000930_chaptered.pdf Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs California Diabetes Program, California Department of Public Health http://caldiabetes.org/Colorado Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance4,861,5152,60028,00070,00031,00027,000159,6004,077,000State Laws and Regulations Colorado Statute: ST §10-16-104 (subsection 13): Mandatory coverage provisions; ST § 10-16-105: Small group sickness and accident insurance, guaranteed issue, mandated provisions for basic health benefit plans, rules, benefit design advisory committee.

Date enacted: 1998. Insurance Policies Required to Provide Coverage Any health benefit plan, except supplemental policies that cover a specified disease or other limited benefit, that provides hospital, surgical or medical expense insurance shall provide coverage for diabetes.

People Covered by Insurance Mandates“Patient with diabetes” means a person with elevated blood glucose levels who has been diagnosed as having diabetes by an appropriately licensed health care professional. Benefits Required Medication: N/ANot mentioned. Equipment and Supplies: Yes Not specified. Education: Yes Medical nutrition therapy included. Services: Yes Outpatient self-management training. Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information.

Copayments/Deductibles Benefits are subject to the same annual deductibles or copayments established for all other covered benefits within a given policy. Private third-party payers shall not reduce or eliminate coverage due to the requirements of this law.

Special Features and Issues Coverage for Amputees: §10-16-104 (subsection 14): Any health benefit plan, except supplemental policies that cover a specified disease or other limited benefit, that provides hospital, surgical or medical expense insurance shall provide coverage for benefits for prosthetic devices that equal those benefits provided for under federal law for health insurance for the aged and disabled.

Statute Web Linkhttp://www.michie.com/colorado/lpext.dll?f=templates&fn=main-h.htm&cp=Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: Disease Management/Patient Education Program includes diabetes under the program Diabetes Disease Management.

Program administrator: Mc Kesson Health Solutions Inc. **Covered as durable medical equipment. Diabetes Prevention and Control Programs Colorado Diabetes Prevention and Control Program, Colorado Department of Public Health and Environment http://www.cdphe.state.co.us/pp/diabetes/index.html Connecticut Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance3,502,309 3,200 27,000 70,000 34,000 33,000 170,200 3,150,000State Laws and Regulations CT ST §38a-492d: Mandatory coverage for diabetes testing and treatment; CT ST §38a-492e: Mandatory coverage for diabetes outpatient self-management training; CT ST §38a-518d: Mandatory coverage for diabetes testing and treatment; CT ST §38a-518e: Mandatory coverage for diabetes outpatient self-management training.

Date enacted: 1999. Insurance Policies Required to Provide Coverage Each individual health insurance policy that provides coverage delivered, issued for delivery or renewed in this state on or after Oct 1, 1997, shall provide coverage for laboratory and diagnostic tests for all types of diabetes.

People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Not specified. Education: Yes Medical nutrition therapy included. Services: Yes Outpatient self-management training; initial training visits provided to an individual after the initial diagnosis of diabetes.

Copayments/Deductibles Benefits shall be subject to the same terms and conditions applicable to all other benefits under such policies.

Special Features and Issues CT law (CT Sec. 38a-523) requires an insurer to cover prosthetic devices under its policy, as it would any other medical procedure. Enacted in 1987. Statute Web Linkhttp://search.cga.state.ct.us/dtsearch_pub_statutes.html Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Connecticut Diabetes Prevention and Control Program, Connecticut Department of Public Health http://www.ct.gov/dph/cwp/view.asp?a=3135&q=397524Delaware Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance864,764 500 11,000 19,000 11,000 8,000 49,500 766,000State Laws and Regulations Delaware Code: 18§3344: Health Insurance Coverage; 18§3560: Insurance coverage for diabetes.

Date enacted: June 2000. Insurance Policies Required to Provide Coverage Every individual or group hospital service corporation contract, individual or group medical service corporation contract, individual or group health service corporation contract, individual health insurance policy, group health insurance policy, and contract for health care services that provides hospital, outpatient services, or medical expense benefits and provides coverage for prescription drugs and that is delivered, issued, executed, or renewed in this State pursuant to Title 18 of the Delaware Code or is approved for issuance or renewal in this State by the Insurance Commissioner shall provide benefits to any subscriber or other person covered there under for expenses incurred for the following equipment and supplies for the treatment of diabetes (see below), if recommended in writing or prescribed by a physician.

People Covered by Insurance Mandates Type of diabetes not specified. Benefits Required Medication: Yes Pharmacological agents for controlling blood sugar.

Insulin. Equipment and Supplies: Yes Insulin pumps. Blood glucose meters and strips. Urine testing strips. Syringes. Education: No N/AServices: No N/ACopayments/Deductibles Not specified. Special Features and Issues Delaware requires coverage of supplies only when the contract or insurance policy provides prescription drug coverage.

Statute Web Linkhttp://delcode.delaware.gov/sessionlaws/ga140/chp376.shtml Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Delaware Diabetes Prevention and Control Program, Delaware Health and Social Services http://www.dhss.delaware.gov/dph/dpc/diabetes.html Florida Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance18,251,243 9000 161,000 458,000 264,000 225,000 1,121,000 14,426,000State Laws and Regulations Florida Statutes: FL ST §627.6408: Diabetes Treatment Services; FL ST §627.65745: Group, Blanket and Franchise.

Health Insurance Policies; FL ST §641.31: Health Maintenance Contracts. Date enacted: 1995. Insurance Policies Required to Provide Coverage A health insurance policy or group, blanket and franchise health insurance policy, and each health maintenance organization and prepaid health plan. People Covered by Insurance Mandates Patients with diabetes; type of diabetes not specified. Benefits Required Medication: N/ANot mentioned.

Equipment and Supplies: Yes Insulin pumps covered if a qualified doctor deems medically necessary. Education: Yes Not specified, but does not include medical nutritional therapy. Services: Yes Outpatient self-management training.

Copayments/Deductibles Not specified. Special Features and Issues N/AStatute Web Link N/APublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education Program includes diabetes. Program administrator: Pfizer Health Solutions. State has a mail order pharmacy benefit under its diabetes demonstration waiver.

Diabetes Prevention and Control Programs Florida Diabetes Prevention and Control Program, Florida Department of Health http://www.floridadiabetes.org/Georgia Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance9,544,7505,600114,000222,000100,00071,000516,6007,831,000State Laws and Regulations 2010 Georgia Code §33-24-59.2. Effective date: July 1, 2002. (Link updated 8/28/2016)Insurance Policies Required to Provide Coverage Every individual major medical and group health insurance policy, group health insurance plan or policy, and any other form of managed or capitated care plans or policies is subject to statute.

People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes Pharmacologic agents. Equipment and Supplies: Yes Not specified. Education: Yes Medical nutrition therapy included. Services: Yes Outpatient self-management training.

Copayments/Deductibles Subject to the same annual deductibles or coinsurance established for all other covered benefits within a given policy. Special Features and Issues N/AStatute Web Linkhttp://www.legis.state.ga.us/legis/2003_04/gacode/33-24-59.2.html Public Programs Medicaid CHIPPrescribed Insulin: Covered* Covered Disposable Needles: Covered* Covered Syringe Combinations: Covered* Covered Blood Glucose Strips: Covered* Covered Notes: Disease Management/Patient Education Program includes diabetes under the Georgia Enhanced Care Program.

Program administrator: Georgia Medicaid. *Covered with Restrictions: Novo Nordisk, Lantus and Levemir insulins and disposable needles and syringe combinations used for insulin administration are preferred; certain quantity and age restrictions may apply.

Diabetes Prevention and Control Programs Georgia Diabetes Prevention and Control, Georgia Department of Human Resources - Division of Public Health http://health.state.ga.us/programs/diabetes/index.asp Hawaii Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance1,283,38860010,00033,00016,00013,00072,6001,172,000State Laws and Regulations Hawaii Statutes: HI ST §431:10A-121: Coverage for Diabetes; HI ST §432:1-612: Group Health Contracts.

Insurance Policies Required to Provide Coverage Each policy of accident and health or sickness insurance that provides coverage for health care, other than an accident only, specified disease, hospital indemnity, Medicare supplement, long-term care, or other limited benefit health insurance policy, that is issued or renewed in this state, shall provide coverage.

People Covered by Insurance Mandates Patients with diabetes; type of diabetes not specified. Benefits Required Medication: N/ANot mentioned. Equipment and Supplies: Yes Not specified. Education: Yes Not specified, but medical nutritional therapy is not covered.

Services: Yes Self-management training Copayments/Deductibles Not specified. Special Features and Issues N/AStatute Web Linkhttp://www.capitol.hawaii.gov/hrscurrent/Vol09_Ch0431-0435E/HRS0431/HRS_0431-0010A-0121.htm Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: **Covered as durable medical equipment.

Diabetes Prevention and Control Programs Hawaii Diabetes Prevention and Control Program, Hawaii Department of Health http://hawaii.gov/health/family-child-health/chronic-disease/diabetes/index.html Idaho Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance1,499,402 900 10,000 29,000 15,00011,00066,900 1,292,000State Laws and Regulations No applicable statute.

Idaho is one of four states that does not have a mandate or insurance requirement specific to diabetes coverage.

Insurance Policies Required to Provide Coverage N/APeople Covered by Insurance Mandates N/ABenefits Required Medication: No N/AEquipment and Supplies: No N/AEducation: No N/AServices: No N/ACopayments/Deductibles N/ASpecial Features and Issues N/AStatute Web Link N/APublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: Disease Management/Patient Education Program includes diabetes under the program Pay for Performance Disease Management. Program administrator: Paul Leary, Medicaid Deputy Administrator. ** Covered as durable medical equipment.

Diabetes Prevention and Control Programs Idaho Diabetes Control and Prevention Program Coordinator, Idaho Department of Health and Welfare http://healthandwelfare.idaho.gov/Health/Diseases Conditions/Diabetes/tabid/175/Default.aspx Illinois Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance12,852,548 7,100 91,000 319,000 143,000 107,000 667,100 10,988,000State Laws and Regulations215 ILCS 5/356w - (H. 3427): Diabetes Coverage.

Date enacted: 1998. Insurance Policies Required to Provide Coverage A group policy of accident and health insurance that is amended, delivered, issued or renewed after the effective date of this amendatory act of 1998 shall provide coverage. People Covered by Insurance Mandates Type 1 diabetes Type 2 diabetes Gestational diabetes mellitus Benefits Required Medication: Yes Oral medications (to manage blood sugar).

Equipment and Supplies: Yes Blood glucose monitors. Cartridges. Lancets and lancing devices. Insulin. Syringes. Pen needles. Test strips. Glucagon kits. Education: Yes Medical nutritional therapy included. Services: Yes Outpatient self-management training. Copayments/Deductibles Coverage under this subsection for diabetes self-management training shall be subject to the same deductible, copayment, and coinsurance provisions that apply to coverage under the policy for other services provided by the same type of provider.

Special Features and Issues The equipment will be covered only if the insurance policy offers durable medical equipment benefits coverage.

Statute Web Linkhttp://www.ilga.gov/legislation/ilcs/documents/021500050K356w.htm Public Programs Medicaid CHIPPrescribed Insulin: Covered* Covered*Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered* Covered Notes: *Covered with restrictions: Preferred drug list applies.

Diabetes Prevention and Control Programs Illinois Diabetes Prevention & Control Program (DPCP), Illinois Department of Human Services http://www.dhs.state.il.us/page.aspx?item=33873Indiana Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance6,345,2893,50059,000161,00091,00058,000376,5005,546,000State Laws and Regulations Indiana Statutes: IN ST 27-8-14.5-1: ""Health insurance plan"" defined; IN ST 27-8-14.5-2: ""Insured"" defined; IN ST 27-8-14.5-3: ""Insurer"" defined; IN ST 27-8-14.5-4: Coverage for treatments, supplies, and equipment; IN ST 27-8-14.5-5: Deductible, copayment, and coinsurance provisions; IN ST 27-8-14.5-6: Coverage for diabetes self-management training; IN ST 27-8-14.5-7: Adoption of rules.

Date enacted: 1997. Insurance Policies Required to Provide Coverage “Insurer” means any person who provides health insurance and issues health insurance plans in Indiana.

The term includes the following: A licensed insurance company. A prepaid hospital or medical service plan. A health maintenance organization. A state employee health benefit plan. The state Medicaid plan.

Any person providing a plan of health insurance subject to state insurance law. People Covered by Insurance Mandates Any individual, covered by a health insurance plan issued by an insurer, who has: Insulin-using diabetes;Non-insulin using diabetes; or Elevated blood glucose levels induced by pregnancy or another medical condition. Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Not specified. Education: Yes Not specified.

Services: Yes Self-management training: One or more visits after receiving a diagnosis of diabetes, one or more visits for reeducation or refresher training. Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information.

Copayments/Deductibles An insured may not be required to pay an annual deductible or copayment that is greater than an annual deductible or copayment established for similar benefits under the health insurance plan.

If the plan does not cover a similar benefit, the copayment or deductible may not be set at a level that materially diminishes the value of the diabetes benefit required by this chapter. An insured may be subject to coinsurance that is not greater than coinsurance established for similar benefits under the health insurance plan.

If the plan does not cover a similar benefit, the coinsurance may not be set at a level that materially diminishes the value of the diabetes benefit required by this chapter. Special Features and Issues Coverage for Amputees: IC 27-8-24.2: A policy of accident and sickness insurance must provide coverage for orthotic devices and prosthetic devices, including repairs or replacements.

Statute Web Linkhttp://www.in.gov/legislative/ic/code/title27/ar8/ch14.5.html Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered*Disposable Needles: Covered Covered*Syringe Combinations: Covered Covered*Blood Glucose Strips: Covered Covered*Notes: *Some yearly limits may apply.

Diabetes Prevention and Control Programs Indiana Diabetes Prevention and Control Program, Indiana State Department of Health http://www.in.gov/isdh/19701.htm Iowa Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance2,988,046 1,600 19,000 62,000 30,000 38,000 151,600 2,695,000State Laws and Regulations IA ST §514C.18.

Date enacted: 1999. Insurance Policies Required to Provide Coverage Policies or contracts providing for third-party payment or prepayment of health or medical expenses. This section applies to the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after July 1, 1999.

People Covered by Insurance Mandates Patients with diabetes; all types of diabetes mellitus. Benefits Required Medication: No N/AEquipment and Supplies: Yes Blood glucose, meter and glucose strips for home monitoring. Education: Yes Not specified. Services: Yes Self-management training. Copayments/Deductibles Not specified.

Special Features and Issues N/AStatute Web Linkhttp://www.legis.state.ia.us/GA/78GA/Legislation/S/03000/S03022/Current.html Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education program includes diabetes under IME Care Management. Program administrator: Iowa Medicaid Enterprise. Diabetes Prevention and Control Programs Iowa Diabetes Prevention and Control Program, Iowa Department of Public Health http://www.idph.state.ia.us/hpcdp/diabetes.asp Kansas Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance2,775,9971,600 24,000 56,000 29,000 27,000 137,600 2,376,000State Laws and Regulations KS ST § 40-2,163.

Date enacted: July 1, 1998. Insurance Policies Required to Provide Coverage Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization that provides coverage for accident and health services and that is delivered, issued for delivery, amended or renewed on or after Jan 1, 1999.

People Covered by Insurance Mandates Insulin dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes Insulin. Equipment and Supplies: Yes Hypodermic needles. Education: Yes Medical nutritional therapy included. Services: Yes Outpatient self-management training. Copayments/Deductibles The benefits provided in this act shall be subject to the same annual deductible or coinsurance and the same requirement of medical necessity established for all other covered benefits within a given policy.

Special Features and Issues N/AStatute Web Linkhttp://www.kslegislature.org/li/statute/Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered*** Covered Syringe Combinations: Covered*** Information not available Blood Glucose Strips: Covered** Covered Notes: The provisions of this act shall not apply to any Medicare supplement policy of insurance, as defined by the commissioner of insurance by rule and regulation or any policy of long-term care insurance.

**Covered as durable medical equipment. ***Need prior authorization and covered as durable medical equipment.

Diabetes Prevention and Control Programs Kansas Diabetes Prevention and Control Program, Kansas Department of Health and Environment http://www.kdheks.gov/diabetes/index.htm Kentucky Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance4,241,474 2,200 46,000 125,000 51,000 38,000 263,200 3,637,000State Laws and Regulations KY ST §304.17A-148: Coverage for diabetes; KY ST §304.17A-096: Basic health benefit plans permitted for individual, small group and association markets; Required coverage; Exclusions from coverage.

Date enacted: 1998. Insurance Policies Required to Provide Coverage All health benefit plans issued or renewed on or after July 15, 1998, shall provide coverage. Insurers in the individual, small group or employer-organized association markets that offer a basic health benefit plan. People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes All medications necessary to treat diabetes, if prescribed by a health care provider legally authorized to prescribe the items.

Equipment and Supplies: Yes Not specified. Education: Yes Medical nutritional therapy included. Services: Yes Outpatient self-management training. Copayments/Deductibles The benefits provided in this section shall be subject to the same annual deductibles or coinsurance established for all other covered benefits within a given health benefit plan.

Special Features and Issues N/AStatute Web Linkhttp://www.lrc.ky.gov/krs/304-17a/148.pdf Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Not covered Not covered Syringe Combinations: Covered Covered Blood Glucose Strips: Not covered Not covered Notes: N/ADiabetes Prevention and Control Programs Kentucky Diabetes Prevention and Control Program, Kentucky Cabinet for Health and Family Services http://chfs.ky.gov/dph/info/dpqi/cd/diabetes.htm Louisiana Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance4,293,204 2,400 41,000 132,000 60,000 35,000 271,400 3,421,000State Laws and Regulations LA R. S. 22:1034.

Date enacted: 1997. Insurance Policies Required to Provide Coverage Any hospital, health, or medical expense insurance policy, hospital or medical service contract, health and accident insurance policy, or any other contract of this type providing comprehensive major medical benefits, including a group insurance plan, or any policy of family group, blanket, or association health and accident insurance, a self-insurance plan, an employee welfare benefit plan, or a health maintenance organization subscriber agreement that is issued or renewed in this state on or after Jan 1, 1998, or the Office of Group Benefits programs shall provide coverage.

People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin using diabetes Benefits Required Medication: N/ANot mentioned.

Equipment and Supplies: Yes Not specified. Education: Yes Medical nutritional therapy included. Services: Yes One-time evaluation and training program per policy for diabetes self-management when medically necessary as determined by a physician. Copayments/Deductibles The benefits provided in this section shall be subject to the same annual deductibles or coinsurance established for all other covered benefits within a given policy.

Special Features and Issues The provisions of the section shall not apply to individually underwritten, guaranteed renewable or renewable limited benefit supplemental health insurance policies authorized to be issued in this state. LA legislation requires an insurer to cover prosthetic devices under its policy, as it would any other medical procedure. This was enacted in 2008. Statute Web Linkhttp://www.legis.state.la.us/lss/lss.asp?doc=507874Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Louisiana Diabetes Program, Louisiana Department of Health and Hospitals http://www.dhh.louisiana.gov/offices/?

ID=247Maine Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance1,317,207 600 13,000 34,000 16,000 14,000 77,600 1,197,000State Laws and Regulations ME ST T. 24 §2332-F: Individual and group nonprofit hospital and medical services plan policies; ME ST T. 24-A §2754 : Individual health policies and contracts; ME ST T. 24-A §2847-E: Group and blanket health insurance; ME ST T. 24-A §4240: Health maintenance organizations.

Date enacted: 1996. Insurance Policies Required to Provide Coverage All individual and group nonprofit hospital and medical services plan policies, contracts and certificates and all nonprofit health care plan policies, contracts and certificates; all individual health policies and contracts, except accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term care and other limited benefit health insurance policies and contracts, must provide coverage for the medically appropriate and necessary equipment used to treat diabetes. People Covered by Insurance Mandates Patients with diabetes; type of diabetes not specified. Benefits Required Medication: Yes Insulin.

Equipment: Yes Not specified. Supplies: Yes Oral hypoglycemic agents. Blood glucose monitors. Test strips, lancets and syringes. Education: Yes Not specified. Services: Yes The Ambulatory Diabetes Education and Follow-Up Diabetes Self-Management Training Program authorized by the state’s Diabetes Prevention and Control Program within the Department of Health and Human Service's Maine Centers for Disease Control and Prevention. Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information. Copayments/Deductibles Not specified. Special Features and Issues Coverage for amputees: 22 §3174-FF.

Maine Care Basic. Statute Web Linkhttp://janus.state.me.us/legis/statutes/24-A/title24-Asec2754.html Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Maine Diabetes Prevention and Control Program, Maine Department of Health & Human Services http://www.maine.gov/dhhs/bohdcfh/dcp/Maryland Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance5,618,344 3,000 54,000 128,000 70,000 45,000 302,000 4,804,000State Laws and Regulations MD INSURANCE §15-706: Dietitians and nutritionists; MD INSURANCE §15-822: Coverage for diabetes equipment, supplies and self-management training.

Date enacted: 1997. Insurance Policies Required to Provide Coverage Insurers and nonprofit health service plans that provide hospital, medical or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies that are issued or delivered in the State; and health maintenance organizations that provide hospital, medical or surgical benefits to individuals or groups under contracts that are issued or delivered in the state.

People Covered by Insurance Mandates Insulin-using diabetes Non-insulin-dependent diabetes Elevated blood glucose levels induced by pregnancy Benefits Required Medication: N/ANot mentioned. Equipment and Supplies: Yes Not specified. Education: Yes Medical nutrition therapy included. Services: Yes Outpatient self-management training.

Copayments/Deductibles The coverage required under this section may be subject to the annual deductibles or coinsurance requirements imposed by an entity subject to this section for similar coverage under the same health insurance policy or contract. Special Features and Issues MD (§15-820) requires an insurer to cover prosthetic devices under its policy, as it would any other medical procedure.

Enacted in 1997. Statute Web Linkhttp://law.justia.com/maryland/codes/2005/gin/15-706.html Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered** Covered Notes: ** Covered as durable medical equipment.

Diabetes Prevention and Control Programs Maryland Diabetes Prevention and Control, Maryland Department of Health and Mental Hygiene http://www.fha.state.md.us/cdp/diabetes.cfm Massachusetts Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance6,449,755 4,800 48,000 129,000 63,000 54,000 302,800 6,000,000State Laws and Regulations MA ST 32A §17G: Group Insurance Commission coverage; MA ST 118E §10C: Required coverage for items medically necessary for diagnosis or treatment of diabetes; MA ST 175 §47N: Corporations; MA ST 176A §8P: Nonprofit Hospital Service Corporations; MA ST 176B §4S: Medical Service Corporations; MA ST 176G §4H: Health Maintenance Organizations.

Date enacted: 2000. Insurance Policies Required to Provide Coverage Contributory group general or blanket insurance for those in the service of the Commonwealth.

An individual policy of accident and sickness insurance issued pursuant to section 108 that provides hospital expense and surgical expense insurance. Any group blanket policy of accident and sickness insurance issued pursuant to section 110 that provides hospital expense and surgical expense insurance. A contract between a subscriber and the corporation under an individual or group hospital service plan that provides hospital expense and surgical expense insurance.

A subscription certificate under an individual or group medical service agreement that provides hospital expense and surgical expense insurance.

Any individual or group health maintenance contract. People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-dependent diabetes Benefits Required Medication: Yes Insulin. Prescribed oral diabetes medications that influence blood sugar levels. Equipment and Supplies: Yes Blood glucose monitors. Blood glucose monitoring strips for home use. Voice-synthesizers for blood glucose monitors for use by the legally blind.

Visual magnifying aids for use by the legally blind. Urine glucose strips; ketone strips. Lancets. Insulin syringes. Laboratory tests, including glycosylated hemoglobin, or Hb Alc, tests. Urinary protein/microalbumin and lipid profiles. Insulin pumps and insulin pump supplies. Insulin pens. Therapeutic/molded shoes and shoe inserts for people who have severe diabetic foot disease.

Education: Yes Medical nutritional therapy included, when provided by a certified diabetes health care provider participating with the health maintenance contract or affiliated with a provider participating with the health maintenance contract. Services: Yes Outpatient self-management training, when provided by a certified diabetes health care provider participating with the health maintenance contract or affiliated with a provider participating with the health maintenance contract.

Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information. Copayments/Deductibles Not specified. Special Features and Issues Coverage for Amputees: Chapter 176A: Section 8AA: Coverage of prosthetic devices and repairs.

Statute Web Linkhttp://www.mass.gov/legis/laws/mgl/32a-17g.htm Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Massachusetts Diabetes Prevention and Control Program, Massachusetts Department of Health and Human Services http://www.mass.gov/dph/diabetes Michigan Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance10,071,822 5,500 96,000 279,000 114,000 107,000 604,500 8,776,000State Laws and Regulations MI ST 500.3406p: Establishment of program to prevent onset of clinical diabetes required; report; coverage; “diabetes” defined; MI ST 550.1416b: Health Care Corporation.

Date enacted: 2000. Insurance Policies Required to Provide Coverage A health care corporation certificate shall provide benefits in each group and nongroup certificate for medically necessary medications prescribed by an allopathic, osteopathic or podiatric physician and used to treat foot ailments, infections and other medical conditions of the foot, ankle or nails associated with diabetes.

An insurer providing an expense-incurred hospital, medical or surgical policy or certificate delivered or issued for delivery in this state and a health maintenance organization shall establish and provide to insureds, enrollees and participating providers a program to prevent the onset of clinical diabetes.

This program for participating providers shall emphasize best practice guidelines to prevent the onset of clinical diabetes and to treat diabetes, including, but not limited to, diet, lifestyle, physical exercise and fitness, and early diagnosis and treatment. People Covered by Insurance Mandates Gestational diabetes Insulin-dependent diabetes Non-insulin-dependent diabetes Benefits Required Medication: Yes Insulin, if prescribed by an allopathic or osteopathic physician.

Nonexperimental medication for controlling blood sugar, if prescribed by an allopathic or osteopathic physician. Medications used to treat of foot ailments, infections and other medical conditions of the foot, ankle or nails associated with diabetes, if prescribed by an allopathic, osteopathic or podiatric physician.

Equipment and Supplies: Yes Blood glucose monitors and blood glucose monitors for the legally blind. Test strips for glucose monitors. Visual reading and urine testing strips. Lancets and spring-powered lancet devices.

Syringes. Insulin pumps and medical supplies required for the use of an insulin pump. Education: Yes Not specified. Services: Yes Diabetes self-management training. Copayments/Deductibles Not specified. Special Features and Issues MI Sec 550.1415 requires an insurer to cover prosthetic devices under its policy, as it would any other medical procedure.

Enacted in 1986. Statute Web Linkhttp://www.legislature.mi.gov/ (S (w3htol45kaxvgxfpbbi1sljj))/mileg.aspx?page=get Object&object Name=mcl-500-3406p Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: **Covered as durable medical equipment.

Diabetes Prevention and Control Programs Michigan Diabetes Prevention & Management, Michigan Department of Community Health http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_2980---,00.html Minnesota Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance5,197,621 2,800 32,000 86,000 43,000 47,000 210,800 4,758,000State Laws and Regulations MN ST §62A.3093: Coverage for diabetes; MN ST §62A.316: Basic Medicare supplement plan; coverage.

Date enacted: 1997. Insurance Policies Required to Provide Coverage A health plan, including a plan providing the coverage specified in section 62A.011, subdivision 3, clause 1 (10) (defining a “health plan” as a policy or certificate of accident and sickness insurance offered by an insurance company licensed under chapter 60A). People Covered by Insurance Mandates Type I diabetes Type II diabetes Gestational diabetes Benefits Required Medication: Yes Not specified.

Equipment and Supplies: Yes All physician-prescribed medically appropriate and necessary equipment and supplies used to manage and treat diabetes. Education: Yes Medical nutrition therapy included. Services: Yes Diabetes outpatient self-management training.

Copayments/Deductibles Coverage required under this section is subject to the same deductible or coinsurance provisions applicable to the plan’s hospital, medical expense, medical equipment, or prescription drug benefits.

A health carrier may not reduce or eliminate coverage due to this requirement. Special Features and Issues N/AStatute Web Linkwww.revisor.mn.gov/bin/getpub.php?pubtype=stat_chap&year=2007§ion=62a Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Limited coverage Blood Glucose Strips: Covered** Covered Notes: Medicare Part D: A health plan providing the coverage specified in MN section 62A.011, subdivision 3, clause (10), is not subject to the requirements of subdivision 1, clause (1), with respect to equipment and supplies covered under the Medicare Part D Prescription Drug program, whether or not the covered person is enrolled in a Medicare Part D plan.

This exception does not apply to a health plan providing the coverage specified in section 62A.011, subdivision 3, clause (10), that was in effect on Dec 31, 2005, if the covered person remains enrolled in the plan and does not enroll in a Medicare Part D plan.

The basic Medicare supplement plan must have a level of coverage that will provide 80 percent of coverage for all physician-prescribed medically appropriate and necessary equipment and supplies used in the management and treatment of diabetes not otherwise covered under Part D of the Medicare program.

Diabetes Prevention and Control Programs Minnesota Diabetes Program, Minnesota Department of Health http://www.health.state.mn.us/diabetes/Mississippi Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance2,918,785 1,700 41,000 90,000 45,000 29,000 207,700 2,358,000State Laws and Regulations Miss.

Code Ann. MS ST § 83-9-46. Date enacted: 1998. Insurance Policies Required to Provide Coverage Mississippi is one of three states that require health insurers to offer at least one type of policy that includes coverage of diabetes treatment, but does not require such coverage as a mandated benefit.

The law states:""Except as otherwise provided herein, from and after Jan 1, 1999, all individual and group health insurance policies or plans, pooled risk policies and all other forms of managed/capitated care plans or policies regulated by the State of Mississippi shall offer coverage for diabetes treatments. ""People Covered by Insurance Mandates All forms of diabetes, regardless of mode of treatment if such treatment is prescribed by a health care professional legally authorized to prescribe such treatment and regardless of the age of onset or duration of the disease.

Benefits Required Medication: N/ANot mentioned. Equipment and Supplies: Yes Equipment and supplies used in connection with monitoring blood glucose and insulin administration and self-management training/education and medical nutrition therapy in an outpatient, inpatient or home health setting.

Education: Yes Medical nutritional therapy included. Services: Yes Self-management training. Copayments/Deductibles The benefits provided in this section shall be subject to the same annual deductibles or coinsurance established for all other covered benefits within a given policy.

Special Features and Issues The coverage shall be offered on an optional basis, and each primary insured must accept or reject such coverage in writing and accept responsibility for premium payment.

Statute Web Linkhttp://www.michie.com/mississippi/lpext.dll?f=templates&fn=main-h.htm&cp=Public Programs Medicaid CHIPPrescribed Insulin: Covered Limited coverage Disposable Needles: Not covered Limited coverage Syringe Combinations: Not covered Limited coverage Blood Glucose Strips: Not covered Limited coverage Notes: Pays pharmacies $20 for average 30-minute encounter for disease management services for specified disorders, including diabetes. Diabetes Prevention and Control Programs Mississippi Diabetes Prevention & Control Program, Mississippi State Department of Health http://www.msdh.state.ms.us/msdhsite/_static/43,0,296.html Missouri Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance5,878,415 3,200 56,000 145,000 70,000 54,000 328,200 5,062,000State Laws and Regulations MO ST 376.385.

Date enacted: 1997. Insurance Policies Required to Provide Coverage Missouri is one of three states that require health insurers to offer at least one type of policy that includes coverage of diabetes treatment, but does not require such coverage as a mandated benefit.

The law states:""Each entity that offers individual and group health insurance policies that provide coverage on an expense-incurred basis, individual and group service or indemnity type contracts issued by a health services corporation, individual and group service contracts issued by a health maintenance organization, all self-insured group arrangements, to the extent not preempted by federal law, and all managed health care delivery entities of any type or description, that are delivered, issued for delivery, continued or renewed in this state on or after Jan 1, 1998, shall offer coverage.

""People Covered by Insurance Mandates Type I diabetes Type II diabetes Gestational diabetes Benefits Required Medication: N/ANot mentioned. Equipment and Supplies: Yes Coverage for all physician-prescribed medically appropriate and necessary equipment, supplies and self-management training used to manage and treat diabetes.

Education: Yes Not specified. Services: Yes Self-management training. Copayments/Deductibles No greater than any other health care service provided by the policy. Special Features and Issues N/AStatute Web Link Web link not available for statute. Public Programs Medicaid CHIPPrescribed Insulin: Covered N/ADisposable Needles: Covered N/ASyringe Combinations: Covered N/ABlood Glucose Strips: Covered N/ANotes: Payment for cognitive services is provided to qualified pharmacies that enroll to provide specified services, including diabetes.

Disease Management/Patient Education Program includes diabetes. Program administrator: State of Missouri.

Diabetes Prevention and Control Programs Missouri Diabetes Prevention and Control Program, Missouri Department of Health and Senior Services http://www.dhss.mo.gov/living/healthcondiseases/chronic/diabetes/index.php Montana Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance957,861 500 6,000 18,000 9,000 8,000 41,500 793,000State Laws and Regulations MT ST 2-18-704: Mandatory provisions; MT ST 33-22-129: Coverage for outpatient self-management training and education for treatment of diabetes; limited benefit for medically necessary equipment and supplies; MT ST 33-22-262: Limited coverage individual health benefit plan or managed care plan; demonstration project; Criteria; rulemaking; MT ST 33-22-1521: Association plan; minimum benefits; MT ST 33-31-102: Definitions.

Date enacted: 2001. Insurance Policies Required to Provide Coverage Any group disability policy, certificate of insurance, or membership contract is required to provide coverage. Includes state employee group insurance program, university employee group insurance program, and any employee group insurance program of a city, town, or other political subdivision of the state if benefits from such insurance falls below the provisions of the statute.

People Covered by Insurance Mandates Patients with diabetes; type of diabetes not specified. Benefits Required Medication: Yes Insulin. One prescriptive oral agent for controlling blood sugar levels for each class of drug. Equipment and Supplies: Yes Syringes. Injection aids. Devices to self-monitor glucose levels (including those for the visually impaired).

Test strips. Visual reading and urine test strips. One insulin pump for each warranty period. Accessories to insulin pumps. Glucagon emergency kits. Education: Yes Not specified. Services: Yes Outpatient self-management training. Copayments/Deductibles Annual copayment and deductible provisions are subject to the same terms and conditions that apply to all other covered benefits within a given policy.

Special Features and Issues N/AStatute Web Linkhttp://data.opi.mt.gov/bills/mca/2/18/2-18-704.htm Public Programs Medicaid CHIPPrescribed Insulin: Covered*** Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: **Covered as durable medical equipment. ***Need prior authorization. Diabetes Prevention and Control Programs Diabetes Project, Montana Department of Public Health and Human Services.

http://www.dphhs.mt.gov/PHSD/Diabetes/diabetes-index.shtml Nebraska Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance1,774,571 1,000 14,000 35,000 19,000 21,000 90,000 1,522,000State Laws and Regulations NE ST § 44-790.

Date enacted: 1999. Insurance Policies Required to Provide Coverage Any individual or group sickness and accident insurance policy or subscriber contract delivered, issued for delivery, or renewed in this state and any hospital, medical or surgical expense-incurred policy, except for policies that provide coverage for a specified disease or other limited-benefit coverage, and any self-funded employee benefit plan to the extent not preempted by federal law shall include coverage.

People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Blood glucose monitors. Blood glucose monitors for the legally blind.

Test strips for glucose monitors. Urine testing strips. Insulin. Injection aids. Lancet and lancet devices. Syringes. Insulin pumps and all supplies for the pump. Insulin infusion devices. Oral agents for controlling blood sugars. Glucose agents and glucagon kits. Insulin measurement. Administration aids for the visually impaired.

Patient management materials that provide essential diabetes self-management information. Podiatric appliances to prevent complications associated with diabetes. Education: Yes Medical nutritional therapy included. Services: Yes Diabetes self-management training and patient management. Copayments/Deductibles Insurance mandate does not prevent application of a deductible, copayment or network incentives contained in the policy or outpatient care provisions that extend coverage primarily in relation to hospital confinement or surgery.

Special Features and Issues N/AStatute Web Linkhttp://uniweb.legislature.ne.gov/laws/statutes.php?statute=44-790Public Programs Medicaid CHIPPrescribed Insulin: Covered*** Covered***Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes:**Covered as durable medical equipment.

***Need prior authorization. Diabetes Prevention and Control Programs Nebraska Diabetes Prevention & Control Program, Nebraska Department of Health & Human Services http://www.dhhs.ne.gov/diabetes/Nevada Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance2,565,382 1,400 17,000 55,000 27,000 18,000 117,400 2,126,000State Laws and Regulations NV ST 689A.0427: Individual coverage; NV ST 689B.0357: Group; NV ST 695B.1927: Nonprofit corporations for hospital, medical and dental service; NV ST 695C.1727: Health maintenance organization.

Date enacted: 1997. Insurance Policies Required to Provide Coverage Policy of health insurance, group policy of insurance, and contract for hospital or medical service that provides coverage for hospital, medical or surgical expenses, and health maintenance organizations.

People Covered by Insurance Mandates Type I diabetes Type II diabetes Gestational diabetes Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Not specified. Education: Yes Not specified. Services: Yes “Coverage for the self-management of diabetes” includes: Training and education provided to an insured person after he or she is initially diagnosed with diabetes that is medically necessary for the care and management of diabetes, including, without limitation, counseling in nutrition and the proper use of equipment and supplies for the treatment of diabetes.

Training and education that is medically necessary as a result of a subsequent diagnosis that indicates a significant change in the symptoms or condition of the insured person and that requires modification of the program of self-management of diabetes.

Training and education that is medically necessary due to the development of new techniques and treatment for diabetes. Copayments/Deductibles Insurers must provide the coverage required by this section subject to the same deductible, copayment, coinsurance and other such conditions.

Special Features and Issues N/AStatute Web Linkhttp://www.leg.state.nv.us/NRS/NRS-689A.html Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Nevada Diabetes Prevention & Control Program, Nevada Department of Health and Human Services http://health.nv.gov/CD_Diabetes.htm New Hampshire Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance1,315,828 700 10,000 27,000 15,000 12,000 65,700State Laws and Regulations NH ST §415:6-e: Individual policy; NH ST § 415:18-f: Contract of group or blanket accident; NH ST §420-A:17-a: Health service corporations; NH ST §420-B:8-k: Health maintenance organizations.

Date enacted: 1997. Insurance Policies Required to Provide Coverage Each insurer that issues or renews any individual policy, plan or contract of accident or health insurance that provides benefits for medical or hospital expenses shall provide to certificate holders of such insurance, who are residents of this state, coverage for medically appropriate and necessary outpatient self-management training and educational services, pursuant to a written order of a primary care physician or practitioner.

Applies to individual policies from insurers, group or blanket policies from insurers, group or blanket policies from health service corporations, and group or blanket policies from health maintenance organizations.

People Covered by Insurance Mandates Patients with diabetes; type of diabetes not specified. Benefits Required Medication: Yes Medically appropriate or necessary insulin. Oral agents. Equipment and Supplies: Yes Not specified. Education: Yes Medical nutritional therapy included.

Services: Yes Not specified. Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information. Copayments/Deductibles Not specified. Special Features and Issues Insurance companies are required to cover only medically appropriate or necessary diabetes equipment if they provide durable medical coverage.

Insurers are required to cover insulin, oral medications to treat diabetes and equipment, but only if they offer a prescription drug rider. Coverage for Amputees: 415:18-n: Coverage for certain prosthetic devices. Statute Web Linkhttp://www.gencourt.state.nh.us/rsa/html/xxxvii/415/415-6-e.htm Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered*Disposable Needles: Covered Covered*Syringe Combinations: Covered Covered*Blood Glucose Strips: Covered Covered*Notes: * Co-pay required.

Diabetes Prevention and Control Programs New Hampshire Diabetes Education Program, New Hampshire Department of Health & Human Services http://www.dhhs.nh.gov/dphs/cdpc/diabetes/New Jersey Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance8,685,920 4,600 67,000 206,000 111,000 87,000 479,600 7,208,000State Laws and Regulations NJ ST 17:48-6n: Individual, group hospital service corporation; NJ ST 17:48A-7l: Individual, group medical service corporation; NJ ST 17:48E-35.11: Individual group health service corporation; NJ ST 17B:26-2.1l: Individual health insurance policy; NJ ST 17B:27-46.1m: Group health insurance policy; NJ ST 26:2J-4.11: HMO contracts.

Date enacted: 1995. Insurance Policies Required to Provide Coverage Hospital service corporation contracts, medical service corporation contracts, health service corporation contracts, individual health insurance policies, group health insurance policies, and health care services contracts.

People Covered by Insurance Mandates Patients with diabetes; type of diabetes not specified. Benefits Required Medication: Yes Insulin. Oral agents for controlling blood sugar. Equipment and Supplies: Yes Blood glucose monitors and blood glucose monitors for the legally blind.

Test strips for glucose monitors and visual reading and urine testing strips Injection aids. Cartridges for the legally blind. Syringes. Insulin pumps and appurtenances thereto. Insulin infusion devices. Education: Yes Not specified. Services: Yes Self-management training. Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information.

Copayments/Deductibles Benefits shall be provided to the same extent as for any other sickness under the policy.

Special Features and Issues Coverage for amputees: C.17:48-6ff: Hospital service corporation to provide benefits for orthotic and prosthetic appliances Statute Web Link N/APublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs New Jersey Diabetes Prevention & Control, New Jersey Department of Health & Senior Services http://www.state.nj.us/health/fhs/diabetes/index.shtml New Mexico Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance1,969,915 1,100 16,000 43,000 21,000 15,000 97,100 1,509,000State Laws and Regulations NM ST §59A-22-41: Individual and group health insurance policy; NM ST §59A-46-43: Individual and group health maintenance organization contract.

Date enacted: 1997. Insurance Policies Required to Provide Coverage Each individual and group health insurance policy, health care plan, certificate of health insurance and managed health care plan delivered or issued for delivery in the state, and each individual and group health maintenance organization contract delivered or issued for delivery in the state. People Covered by Insurance Mandates Insulin-using diabetes Non-insulin-using diabetes Elevated blood glucose levels induced by pregnancy Benefits Required Medication: Yes Insulin.

Equipment and Supplies: Yes Blood glucose monitors, including those for the legally blind. Test strips for blood glucose monitors. Visual reading urine and ketone strips. Lancets and lancet devices. Injection aids, including those adaptable to meet the needs of the legally blind.

Syringes. Prescriptive oral agents for controlling blood sugar levels. Medically necessary podiatric appliances for prevention of feet complications associated with diabetes, including therapeutic molded or depth-inlay shoes, functional orthotics, custom molded inserts, replacement inserts, preventive devices and shoe modifications for prevention and treatment. Glucagon emergency kits. Education: Yes Medical nutrition therapy included. Services: Yes Self-management training.

Copayments/Deductibles Coverage for people with diabetes may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same contract, as long as the annual deductibles or coinsurance for benefits are no greater than the annual deductibles or coinsurance established for similar benefits within a given contract.

Special Features and Issues N/AStatute Web Linkhttp://www.conwaygreene.com/nmsu/lpext.dll?f=templates&fn=main-h.htm&2.0Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs New Mexico Diabetes Prevention & Control Program, New Mexico Department of Health http://www.diabetesnm.org/New York Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance19,297,729 10,000 171,000 524,000 243,000 201,000 1,160,000 16,543,000State Laws and Regulations NY INS §3216: Individual accident and health insurance policy provisions; NY INS § 3221: Group or blanket accident and health insurance policies; NY INS §4303: Benefits; NY INS §4321: Standardization of individual enrollee direct payment contracts offered by HMOs.

Date: 1993. Insurance Policies Required to Provide Coverage Individual accident and health insurance policy provisions; group or blanket accident and health insurance policies; medical expense indemnity corporation and health service corporations; and direct payment contracts offered by health maintenance organizations.

People Covered by Insurance Mandates Patients with diabetes; Type of diabetes not specified because mandate is not based on the type of diabetes or whether the patient uses insulin.

Benefits Required Medication: Yes Insulin. Oral agents for controlling blood sugar. Oral agents for treating hypoglycemia (e.g. glucose tablets and gels). Equipment and Supplies: Yes Lancets and automatic lancing devices. Glucose test strips. Alcohol swabs, skin prep wipes and IV prep (for cleaning skin). Blood glucose monitors (e.g. glucometers). Blood glucose monitors for the visually impaired. Control solutions used in blood glucose monitors.

Diabetes data management systems to manage blood glucose. Urine testing products for glucose and ketones. Insulin infusion devices. Injection aids (e.g. insulin drawing-up devices for the visually impaired). Cartridges for the visually impaired. Disposable injectable insulin cartridges and pen cartridges. Other disposable injectable medication cartridges and pen needles used for diabetes therapies. Glucagon emergency kits. Syringes. Insulin pumps, equipment and supplies for use of the pump (e.g. batteries, semi-permeable transparent dressings, insertion devices, insulin infusion sets, reservoirs, cartridges, clips, skin adhesive and skin adhesive remover, tools specific to prescribed pump).

Education: Yes See ""Services"" below Services: (Reviewed/updated 12/2014)Self-management training: The law also requires coverage for medically necessary diabetes self-management education and education relating to diet, including home visits, when provided by:1. a physician or other licensed health care provider legally authorized to prescribe treatment,2. staff as part of an office visit for diabetes diagnosis or treatment,3. certified diabetes nurse educator,4.

registered dietitian, or5. certified nutritionist or dietitian. The New York State Department of Health publishes guidance on the law for health care providers at http://www.health.ny.gov/diseases/conditions/diabetes/private_health_insurance_plans.htm. Copayments/Deductibles Subject to same deductibles/copayments as required for similar types of benefits in the insurance policy or contract.

Special Features and Issues The law does not apply to: Medicaid recipients,Union-sponsored benefit plans that are self-insured,Medicare or Medigap (Medicare supplemental policies) beneficiaries,Plans that insure employees in more than one state,Employer-sponsored benefit plans that are self-insured, and Health insurance policies that are not issued in New York State.

Section 4303 (u) of the New York Insurance Law requires coverage for diabetic equipment and supplies (this includes insulin and oral agents for controlling blood sugar, among other things). They carry a copayment; however that copayment would be whatever the office visit co-payment is under that policy.

The NY state Insurance Department has allowed diabetic equipment and supplies to be included under a drug rider but only where the drug rider co-payment was equal to or less than the co-pay that would be applicable under the medical benefit.

Statute Web Linkhttp://public.leginfo.state.ny.us/menugetf.cgi? COMMONQUERY=LAWSPublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education Program includes diabetes under Diabetes Prevention and Control.

Program administrator: Bureau of Chronic Disease Services, New York State Department of Health. Diabetes Prevention and Control Programs New York State Diabetes Prevention and Control Program, New York State Department of Health http://www.nyhealth.gov/diseases/conditions/diabetes/North Carolina Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance9,061,032 5,000 79,000 253,000 113,000 96,000 548,000 7,673,000State Laws and Regulations NC ST § 58-51-61: Policy or contract of accident or health insurance; NC ST § 58-65-91: Hospital service plan or medical service plan; NC ST §58-67-74: Health maintenance organization.

Date enacted: 1997. Insurance Policies Required to Provide Coverage Every policy or contract of accident or health insurance, every preferred provider benefit plan (PPO), every insurance certificate or subscriber contract under any hospital service plan or medical service plan, and every health care plan written by a health maintenance organization (HMO).

People Covered by Insurance Mandates Patients with diabetes; type of diabetes not specified. Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Not specified. Education: Yes Not specified. Services: Yes Diabetes outpatient self-management training.

Copayments/Deductibles The same deductibles, coinsurance and other limitations as apply to similar services covered under the policy, contract or plan shall apply to the diabetes coverage required under this section. Special Features and Issues N/AStatute Web Linkhttp://www.ncleg.net/enactedlegislation/statutes/html/bysection/chapter_58/gs_58-51-61.html Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered*Disposable Needles: Covered Covered*Syringe Combinations: Covered Covered*Blood Glucose Strips: Covered Covered*Notes: * Co-pays required.

Members of certain Native American tribes are exempted from co-pays. Diabetes Prevention and Control Programs North Carolina Diabetes Prevention and Control Branch, North Carolina Division of Public Health http://www.ncdiabetes.org/about Us/index.asp North Dakota Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance639,715 300 4,000 11,000 7,000 8,000 31,300 553,000State Laws and Regulations No applicable statute.

North Dakota is one of four states that does not have a mandate or insurance requirement specific to diabetes coverage.

Insurance Policies Required to Provide Coverage N/APeople Covered by Insurance Mandates N/ABenefits Required Medication: No N/AEquipment and Supplies: No N/AEducation: No N/AServices: No N/ACopayments/Deductibles N/ASpecial Features and Issues N/AStatute Web Link N/APublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs North Dakota Diabetes Prevention and Control Program, North Dakota Department of Health http://www.diabetesnd.org/Ohio Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance11,466,917 6,100 112,000 293,000 157,000 104,000 675,100 9,979,000State Laws and Regulations No applicable statute.

Ohio is one of four states that does not have a mandate or insurance requirement specific to diabetes coverage. Insurance Policies Required to Provide Coverage N/APeople Covered by Insurance Mandates N/ABenefits Required Medication: No N/AEquipment and Supplies: No N/AEducation: No N/AServices: No N/ACopayments/Deductibles N/ASpecial Features and Issues N/AStatute Web Link N/APublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: **Covered as durable medical equipment.

Diabetes Prevention and Control Programs Ohio Diabetes Prevention and Control Program, Ohio Department of Health http://www.odh.ohio.gov/odh Programs/hprr/diabete/diab1.aspx Oklahoma Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance3,617,316 2,000 37,000 103,000 47,000 37,000 227,000 2,920,000State Laws and Regulations OK ST T. 36 §6060.2.

Date enacted: 1996. Insurance Policies Required to Provide Coverage For policies, contracts or agreements issued or renewed on and after Nov 1, 1996, any individual or group health insurance policy, contract or agreement providing coverage on an expense-incurred basis; any policy, contract or agreement issued for individual or group coverage by a not-for-profit hospital service and indemnity and medical service and indemnity corporation; contracts issued by health benefit plans including, but not limited to, health maintenance organizations, preferred provider organizations, health services corporations, physician-sponsored networks, or physician hospital organizations; medical coverage provided by self-insureds that includes coverage for physician services in a physician’s office, including coverage through private third-party payers; coverage provided through the State and Education Employees Group Insurance Board; and every policy, contract or agreement that provides medical, major medical or similar comprehensive type coverage, group or blanket accident and health coverage, or medical expense, surgical, medical equipment, medical supplies, or drug prescription benefits shall, subject to the terms of the policy contract or agreement, include coverage for equipment, supplies and related services.

People Covered by Insurance Mandates Type I diabetes Type II diabetes Gestational diabetes Coverage applies when medically necessary and when recommended or prescribed by a physician or other licensed health care provider legally authorized to prescribe under state laws.

Benefits Required Medication: Yes Insulin. Oral agents for controlling blood sugar. Equipment and Supplies: Yes Blood glucose monitors. Blood glucose monitors to the legally blind. Test strips for glucose monitors. Visual reading and urine testing strips. Injection aids. Cartridges for the legally blind. Syringes. Insulin pumps and appurtenances thereto. Insulin infusion devices. Podiatric appliances for prevention of complications associated with diabetes.

Education: Yes Medical nutritional therapy included. Services: Yes Diabetes self-management training. Copayments/Deductibles May be subject to the same annual deductibles or coinsurance as may be deemed appropriate and as are consistent with those established for other covered policy benefits.

Special Features and Issues N/AStatute Web Linkhttp://webserver1.lsb.state.ok.us/OK_Statutes/Complete Titles/os36.rtf Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: Disease Management/Patient Education Program includes diabetes under the program Pediatric Diabetes Management.

Program administrator: Mike Herndon, D. O. **Covered as durable medical equipment. Diabetes Prevention and Control Programs Oklahoma Diabetes Prevention and Control Program, Oklahoma State Department of Health Visit the website Oregon Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance3,747,455 2,000 32,000 82,000 37,000 30,000 184,000 3,130,000State Laws and Regulations OR ST §743.694.

Date enacted: 2001. Insurance Policies Required to Provide Coverage Group health benefit plans as described in OR ST §743.730 (which specifies that a health benefit plan means any hospital expense, medical expense, or hospital or medical expense policy or certificate, health care service contractor or health maintenance organization subscriber contract).

People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: No N/AEquipment and Supplies: Yes Not specified. Education: Yes An education program credentialed or accredited by a qualified state or national entity. Services: Yes Diabetes self-management program. Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information.

Copayments/Deductibles Not specified. Special Features and Issues Coverage for Amputees: HB 2517: Requires coverage under health insurance policy for prosthetic and orthotic devices Statute Web Linkhttps://www.oregonlegislature.gov/bills_laws/ors/ors743A.html Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: Disease Management/Patient Education Program includes diabetes under the program Care Enhance.

Program administrator: Mc Kesson. **Covered as durable medical equipment. Diabetes Prevention and Control Programs Oregon Diabetes Program, Oregon Department of Human Services http://www.oregon.gov/DHS/ph/diabetes/Pennsylvania Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance12,432,792 6,300 116,000 304,000 174,000 165,000 768,300 11,138,000State Laws and Regulations 40 P. S. §764e.

Date enacted: 1998. Insurance Policies Required to Provide Coverage Any individual or group health, sickness and accident insurance policy, group health insurance plans/policies, and all other forms of managed/capitated care plans/policies or subscriber contract or certificate issued by any entity subject to 40 Pa. C. S. Ch.

61 (relating to hospital plan corporations) or Ch. 63 (relating to professional health services plan corporations) or the act of Dec 29, 1972 (P. L. 1701, No. 364), [FN1] known as the “Health Maintenance Organization Act,” the act of Dec 14, 1992 (P. L. 835, No. 134), [FN2] known as the “Fraternal Benefit Societies Code,” or this act providing hospital or medical/surgical coverage.

This section does not include the following policies: accident only, fixed indemnity, limited benefit, credit, dental, vision, specified disease, Medicare supplement, CHAMPUS (Civilian Health and Medical Program for the Uniform Services) supplement, long-term care, disability income, workers’ compensation or automobile medical payment. People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes Insulin. Pharmacological agents for controlling blood sugar and orthotics. Equipment and Supplies: Yes Blood glucose monitors.

Monitor supplies. Injection aids. Syringes. Insulin infusion devices. Education: Yes Medical nutritional therapy included. Services: Yes Outpatient self-management training. Copayments/Deductibles Subject to the annual deductibles or coinsurance requirements imposed for similar coverage under the same health policy.

Special Features and Issues N/AStatute Web Linkhttp://www.legis.state.pa.us/WU01/LI/LI/CT/HTM/40/40. HTMPublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education Program includes diabetes under the program Access Plus. Program administrator: Mc Kesson. Diabetes Prevention and Control Programs Pennsylvania Diabetes Prevention & Control Program, Pennsylvania Department of Health http://www.portal.state.pa.us/portal/server.pt/community/diabetes/14160Rhode Island Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance1,057,832 500 10,000 21,000 13,000 14,000 57,500 931,000State Laws and Regulations RI ST §27-18-38: Accident and sickness policy; RI ST §27-19-35: Nonprofit hospital service corporations; RI ST § 27-20-30: Nonprofit medical service corporations; RI ST §27-41-44: Health maintenance organizations.

Date enacted: 1996. Insurance Policies Required to Provide Coverage Accident and sickness insurance policies, nonprofit hospital service corporations, nonprofit medical service corporations, and health maintenance organizations. People Covered by Insurance Mandates Insulin treated diabetes Non-insulin treated diabetes Gestational diabetes Benefits Required Medication: Yes Insulin. Oral agents for controlling blood sugar. Equipment and Supplies: Yes Blood glucose monitors and blood glucose monitors for the legally blind. Test strips for glucose monitors and/or visual reading. Injection aids. Cartridges for the legally blind.

Syringes. Insulin pumps and appurtenances to the pumps. Insulin infusion devices. Therapeutic/molded shoes to prevent amputation. Education: Yes Medical nutritional therapy included. Services: Yes Self-management education/training. Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information. Copayments/Deductibles Not specified. Special Features and Issues Coverage for Amputees: 27-18-39: Coverage for prostheses and treatment of physical complications.

Statute Web Linkhttp://www.rilin.state.ri.us/Statutes/TITLE27/27-18/27-18-38. HTMPublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: **Covered as durable medical equipment.

Diabetes Prevention and Control Programs Rhode Island Diabetes Prevention and Control Program, Rhode Island Department of Health http://www.health.ri.gov/disease/diabetes/index.php South Carolina Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance4,407,709 2,400 47,000 140,000 62,000 46,000 299,400 3,664,000State Laws and Regulations SC ST § 38-71-46.

Date enacted: 1999. Insurance Policies Required to Provide Coverage On or after Jan 1, 2000, every health maintenance organization, individual and group health insurance policy, or contract issued or renewed in state must provide coverage. People Covered by Insurance Mandates Diabetes mellitus Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Not specified. Education: Yes Not specified. Services: Yes Outpatient self-management training.

Copayments/Deductibles Not specified. Special Features and Issues N/AStatute Web Linkhttp://www.scstatehouse.gov/cgi-bin/query.exe?first=DOC&querytext=diabetes&category=Code&conid=6171490&result_pos=0&keyval=671Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education Program includes diabetes under the program Diabetes Chronic Care Management. Program administrator: South Carolina Department of Health and Human Services. **Covered as durable medical equipment.

Diabetes Prevention and Control Programs South Carolina Diabetes Prevention & Control Program, S. C. Department of Health and Environmental Control http://www.scdhec.gov/health/chcdp/diabetes/South Dakota Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance796,214 400 5,000 14,000 8,000 9,000 37,400 708,000State Laws and Regulations SD ST §58-17-1.2: Individual policies; SD ST §58-17-1.3: Diabetes coverage not required of 58-17-1.2; SD ST §58-18-83: Group health insurance policy; SD ST §58-18-84: Not required coverage of 58-18-83; SD ST §58-18B-56: Small businesses' group and blanket health insurance; SD ST §58-18B-57: Not required coverage of 58-18B-56; SD ST §58-38-42: Nonprofit medical and surgical plans; SD ST §58-38-43: Not required coverage of 58-38-42; SD ST §58-40-39: Nonprofit hospital service plans; SD ST §58-40-40: Not required coverage of 58-40-39; SD ST §58-41-117: Health maintenance organizations; SD ST §58-41-118: Not required coverage of 58-41-117.

Date enacted: 1999. Insurance Policies Required to Provide Coverage Health insurance policies, group and blanket health insurance policies, regulation of small businesses’ group and blanket health insurance, nonprofit medical and surgical plans, nonprofit hospital service plans, and health maintenance organizations.

People Covered by Insurance Mandates Patients with diabetes; Type of diabetes not specified. Benefits Required Medication: Yes Insulin. Oral agents for controlling blood sugars. Equipment and Supplies: Yes Blood glucose monitors for the legally blind. Test strips for glucose monitors. Urine testing strips. Injection aids. Lancets. Lancet devices.

Syringes. Insulin pumps and all supplies for the pump. Insulin infusion devices prescribed. Glucose agents. Glucagon kits. Insulin measurement and administration aids for the visually impaired. Other medical devices for treatment of diabetes. Education: Yes Medical nutrition therapy included. Services: Yes Diabetes self-management training.

Copayments/Deductibles The benefits provided in this section are subject to the same dollar limits, deductibles, coinsurance and other restrictions established for all other benefits covered in the policy. Special Features and Issues N/AStatute Web Linkhttp://legis.state.sd.us/statutes/Display Statute.aspx? Type=Statute&Statute=58-17-1.2Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs South Dakota Diabetes Prevention & Control Program, South Dakota Department of Health http://doh.sd.gov/Diabetes/Tennessee Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance6,156,719 3,300 62,000 196,000 83,000 48,000 395,300 5,268,000State Laws and Regulations TN ST § 56-7-2605.

Date enacted: 1997. Insurance Policies Required to Provide Coverage Any individual, franchise, blanket or group health insurance policy; medical service plan; contract; hospital service corporation contract; hospital and medical service corporation contract; fraternal benefit society; health maintenance organization; preferred provider organization or managed care organization that provides hospital, surgical or medical expense insurance. People Covered by Insurance Mandates “Patient with diabetes” refers to anyone with elevated blood glucose levels that has been diagnosed as having diabetes by an appropriately licensed health care professional.

Benefits Required Medication: Yes Insulin. Oral hypoglycemic agents. Equipment and Supplies: Yes Blood glucose monitors and blood glucose monitors for the legally blind. Test strips for blood glucose monitors. Visual reading and urine test strips. Injection aids. Syringes.

Lancets. Insulin pumps, infusion devices and appurtenances. Podiatric appliances for prevention of complications associated with diabetes. Glucagon emergency kits. Education: Yes Medical nutrition counseling included. Services: Yes Diabetes outpatient self-management training.

Copayments/Deductibles The benefits required by this section may be subject to the annual deductible and coinsurance established for all other similar benefits within a given policy, program or contract of insurance, so long as the annual deductible and coinsurance for the benefits required by this section are no greater than the annual deductible and coinsurance established for all other similar benefits within that policy, program, or contract of insurance.

Special Features and Issues N/AStatute Web Linkhttp://www.michie.com/tennessee/lpext.dll?f=templates&fn=main-h.htm&cp=Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Cover Rx provides the generic equivalent of the following popular brand drugs: Glucophage® (metformin) and the following covered brand drugs: Lantus®*, Novolin®*, Novo Log®* Patient cost is based on a personal income sliding scale: Up to 100% FPL = $5; 100 -149% FPL = $8; 150-249% FPL = $12.

(updated 11/09) Website: http://www.covertn.gov/web/coverrx_benefits.html Diabetes Prevention and Control Programs Tennessee Project Diabetes, run by the Tennessee Department of Health http://health.state.tn.us/projectdiabetes.htm Texas Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance23,904,380 14,600 211,000 638,000 259,000 151,000 1,279,600 17,742,000State Laws and Regulations TX INS §1358.001: Definition; TX INS §1358.002: Applicability; TX INS §1358.003: Exceptions; TX INS §1358.004: Adoption of minimum standards; TX INS §1358.005: Coverage required; TX INS §1358.051: Definitions; TX INS §1358.052: Applicability; TX INS §1358.053: Exception; TX INS §1358.054: Coverage required; TX INS §1358.055: Diabetes self-management training; TX INS §1358.056: Coverage for new or improved equipment; TX INS §1358.057: Rules; TX INS §1501.0581: Health group cooperatives; TX INS §1507.003: State-mandated health benefits; TX INS §1551.219: Group benefits; TX INS §1575.164: Public school employees group benefits program; TX INS §1601.110: Uniform insurance benefits for employees of the University of Texas system and the Texas A&M University System; TX INS Art.

1.53D. Date enacted: 1997. Insurance Policies Required to Provide Coverage This subchapter applies only to a health benefit plan that provides benefits for medical or surgical expenses incurred as a result of a health condition, accident or sickness, including: (1) an individual, group, blanket, or franchise insurance policy or insurance agreement, a group hospital service contract, or an individual or group evidence of coverage that is offered by: an insurance company; a group hospital service corporation operating under Chapter 842; a fraternal benefit society operating under Chapter 885; a stipulated premium company operating under Chapter 884; or a health maintenance organization operating under Chapter 843.

To the extent permitted by the Employee Retirement Income Security Act of 1974 (29 U. S. C. Section 1001 et seq. ), a health benefit plan that is offered by: a multiple employer welfare arrangement as defined by Section 3 of that Act; or another analogous benefit arrangement; and health and accident coverage provided by a risk pool created under Chapter 172, Local Government Code, notwithstanding Section 172.014, Local Government Code, or any other law.

A health benefit plan provided through a health group cooperative or group benefits program must provide coverage for diabetes equipment, supplies and services as required by Subchapter B, Chapter 1358.

This subchapter does not apply to a plan that provides coverage only for a specified disease; only for accidental death or dismemberment; for wages or payments in lieu of wages for a period during which an employee is absent from work because of sickness or injury; as a supplement to a liability insurance policy; only for dental or vision care; only for indemnity for hospital confinement; a small employer health benefit plan written under Chapter 1501; a Medicare supplemental policy as defined by Section 1882 (g) (1), Social Security Act (42 U. S. C. Section 1395ss); a workers’ compensation insurance policy; medical payment insurance coverage provided under a motor vehicle insurance policy; or a long-term care insurance policy, including a nursing home fixed indemnity policy, unless the commissioner determines that the policy provides benefit coverage so comprehensive that the policy is a health benefit plan as described by Section 1358.002.

People Covered by Insurance Mandates “Qualified enrollee” refers to anyone who is eligible for health care coverage under a health benefit plan and who has been diagnosed with: Insulin dependent diabetes Non-insulin dependent diabetes Elevated blood glucose levels induced by pregnancy Another medical condition associated with elevated blood glucose levels Benefits Required Medication: Yes All supplies, including medications and equipment for the control of diabetes shall be dispensed as written, including brand-name products, unless substitution is approved by the physician or practitioner who issues the written order for the supplies or equipment.

Equipment: Yes Blood glucose monitors, including noninvasive glucose monitors and glucose monitors designed to be used by the blind.

Insulin pumps and associated appurtenances. Insulin infusion devices. Podiatric appliances to prevent complications associated with diabetes. Supplies: Yes Test strips for blood glucose monitors. Visual reading and urine test strips. Lancets and lancet devices. Insulin and insulin analogs. Injection aids. Syringes. Prescriptive and non-prescriptive oral agents for controlling blood sugar levels.

Glucagon emergency kits. Education: Yes Nutrition counseling and instructions on proper use of diabetes equipment and supplies shall be provided or covered. Services: Yes Diabetes self-management training. Copayments/Deductibles A health benefit plan can require a deductible, copayment or coinsurance for coverage provided under this section.

The amount of the deductible, copayment or coinsurance may not exceed the amount of the deductible, copayment or coinsurance required for treatment of other analogous chronic medical conditions. Special Features and Issues N/AStatute Web Linkhttp://www.statutes.legis.state.tx.us/Docs/IN/htm/IN.1358.htm Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education Program includes diabetes under the program Texas Medicaid Enhanced Care Program.

Program administrator: Texas Health and Human Services Commission. Diabetes Prevention and Control Programs Texas Diabetes Council, Texas Department of State Health Services http://www.dshs.state.tx.us/diabetes/http://www.dshs.state.tx.us/diabetes/tdcdaecs.shtm Utah Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance2,645,330 2,000 19,000 34,000 19,000 14,000 89,000 2,317,000State Laws and Regulations UT ST §31A-22-626.

Date enacted: 2000. Insurance Policies Required to Provide Coverage The commissioner shall establish, by rule, minimum standards of coverage for diabetes for accident and health insurance policies that provide a health insurance benefit before July 1, 2000.

People Covered by Insurance Mandates Complete insulin deficiency or type I diabetes Insulin resistant with partial insulin deficiency or type II diabetes Elevated blood glucose levels induced by pregnancy (gestational diabetes)Benefits Required Medication: Yes Insulin.

Prescriptive oral agents for controlling blood glucose levels. Equipment and Supplies: Yes Blood glucose monitors, including those for the legally blind. Test strips for blood glucose monitors. Visual reading urine and ketone strips. Lancets and lancet devices.

Injection aides, including those adaptable to meet the needs of the legally blind, and infusion delivery systems. Syringes. Glucagon kits. Education: Yes Medical nutrition therapy included. Services: Yes Diabetes self-management training and patient management. Copayments/Deductibles Durational limits, amount limits, deductibles and coinsurance for treatment of diabetes are to be equitable or identical to coverage provided for treatment of other illnesses or diseases.

Special Features and Issues N/AStatute Web Linkhttp://le.utah.gov/~code/TITLE31A/htm/31A22_062600.htm Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Utah Diabetes Prevention and Control Program, Utah Department of Health http://health.utah.gov/diabetes/Vermont Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance621,254 300 5,000 12,000 6,000 5,000 27,300 545,000State Laws and Regulations VT ST T. 8 §4089c.

Date enacted: 1997. Insurance Policies Required to Provide Coverage""Insurer” defined as any health insurance company, nonprofit hospital and medical service corporation, and health maintenance organization. The term does not apply to limited coverage for specified disease or other limited benefit coverage.

People Covered by Insurance Mandates Insulin dependent diabetes Insulin using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Not specified. Education: Yes Medical nutrition therapy included. Services: Yes Outpatient self-management training. Coverage for Amputees: Yes See below under ""Special features and issues"" for more detailed information.

Copayments/Deductibles Benefits required to be covered by this section shall be subject to the same dollar limits, deductibles and coinsurance factors within the provisions of the health insurance policy. Special Features and Issues Coverage of Amputees: § 4088f: Prosthetic parity. Statute Web Linkhttp://www.leg.state.vt.us/statutes/fullsection.cfm?

Title=08&Chapter=107&Section=04089c Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs Vermont Diabetes Prevention and Control Program, Vermont Department of Health.

http://healthvermont.gov/prevent/diabetes/diabetes.aspx Virginia Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance7,712,091 4,100 60,000 182,000 85,000 68,000 400,100 6,548,000State Laws and Regulations VA ST §38.2-3418.10. Date enacted: 2000. Insurance Policies Required to Provide Coverage Each insurer that proposes to issue an individual or group hospital policy or major medical policy in the Commonwealth, each corporation proposing to issue an individual or group hospital, medical or major medical subscription contract, and each health maintenance organization providing a health care plan for health care services shall provide coverage for diabetes as provided in this section.

The requirements of this section shall apply to all insurance policies, contracts and plans delivered, issued for delivery, reissued, or extended on and after July 1, 2000, or at any time thereafter when any term of the policy, contract or plan is changed or any premium adjustment is made.

People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: Yes Not specified. Equipment and Supplies: Yes Not specified. Education: Yes Medical nutrition therapy included. Services: Yes In-person outpatient self-management training. Copayments/Deductibles No insurer, corporation or health maintenance organization shall impose upon any person receiving benefits pursuant to this section any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, nor shall any insurer, corporation or health maintenance organization impose any policy-year or calendar-year dollar or durational benefit limitations or maximums for benefits or services provided under this section.

Special Features and Issues N/AStatute Web Linkhttp://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+38.2-3418.10Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered*Disposable Needles: Covered** Covered*Syringe Combinations: Covered Covered*Blood Glucose Strips: Covered** Covered*Notes: Disease Management/Patient Education Program includes diabetes. Program administrator: HMC Inc.**Covered as durable medical equipment. Co-pays required. Diabetes Prevention and Control Programs Virginia Diabetes Prevention & Control Project (DPCP), Virginia Department of Health.

http://www.vahealth.org/cdpc/diabetes/Washington Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance6,468,424 3,400 49,000 140,000 55,000 52,000 299,400 5,773,000State Laws and Regulations WA ST 48.20.391: Disability insurance; WA ST 48.21.143: Group and blanket disability insurance; WA ST 48.44.315: Health care services; WA ST 48.46.272: Health maintenance organizations.

Date enacted: 1997. Reviewed 2016Insurance Policies Required to Provide Coverage Washington requires health insurers to offer at least one type of policy that includes coverage of diabetes treatment.

The benefit plans offered by health maintenance organizations (HMOs) and all group disability insurance contracts and blanket disability insurance contracts.

People Covered by Insurance Mandates Insulin using diabetes Non-insulin using diabetes Elevated blood glucose levels induced by pregnancy Benefits Required Medication: Yes Insulin. Prescriptive oral agents for controlling blood sugar levels. Equipment: Yes Syringes. Injection aids. Blood glucose monitors. Test strips for blood glucose monitors. Visual reading and urine test strips.

Insulin pumps and accessories to the pumps. Insulin infusion devices. Foot care appliances for prevention of complications associated with diabetes. Glucagon emergency kits. Supplies: Yes Not specified. Education: Yes Medical nutritional therapy included. Services: Yes Outpatient self-management training. Copayments/Deductibles Coverage required under this section may be subject to customary cost-sharing provisions established for all other similar services or supplies within a policy. Special Features and Issues Coverage for diabetes equipment and supplies is required only when the contract or insurance policy provides for prescription coverage.

Statute Web Linkhttp://apps.leg.wa.gov/RCW/default.aspx?cite=48.20.391Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education Program includes diabetes.

Program administrator: Mc Kesson. Diabetes Prevention and Control Programs Washington Diabetes Prevention & Control Program, Washington State Department of Health http://www.doh.wa.gov/cfh/diabetes/West Virginia Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance1,812,035 900 25,000 66,000 32,000 29,000 152,900 1,541,000State Laws and Regulations WV ST § 33-15C-1: Diabetes insurance; WV ST § 33-16-16: Group accident or sickness policy; WV ST §33-25E-3: Patient eye care limitations on coverage; WV ST § 33-25E-4: Patient eye care required disclosure.

Date enacted: 1996. Insurance Policies Required to Provide Coverage Any diabetes insurance and group accident or sickness policy that provides major medical or similar comprehensive type medical coverage. Any health benefits policy that includes eye care benefits, including a diabetic retinal examination.

People Covered by Insurance Mandates Insulin dependent diabetes Non-insulin dependent diabetes Gestational diabetes Benefits Required Medication: Yes Insulin. Pharmacological agents for controlling blood sugar. Equipment and Supplies: Yes Blood glucose monitors. Monitor supplies. Injection aids, syringes. Insulin infusion devices. Orthotics and any additional items as promulgated by rule.

Education: Yes Not specified. Services: Yes Self-management education. Copayments/Deductibles Any deductible or coinsurance billed for any service as provided in this section shall apply equally with all other coverages provided by the insurer but not included in this section. Special Features and Issues N/AStatute Web Linkhttp://www.legis.state.wv.us/WVCODE/Chapter Entire.cfm?chap=33&art=15CPublic Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education Program includes diabetes under the program Medicaid Diabetes Management Program.

Program administrator: West Virginia Diabetes Control Network. Diabetes Prevention and Control Programs West Virginia Diabetes Prevention & Control Program, West Virginia Department of Health & Human Resources.

http://www.wvdiabetes.org/Wisconsin Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance5,601,640 3,000 37,000 105,000 56,000 55,000 259,000 5,023,000State Laws and Regulations WI ST 40.52; WI ST 632.895: Disability insurance policies.

Date enacted: 2002. Insurance Policies Required to Provide Coverage Every health insurance policy that covers expenses for the treatment of diabetes - including those offered by the state and the self-insured plan of the state. People Covered by Insurance Mandates Patients with diabetes; Type of diabetes not specified. Benefits Required Medication: Yes Not specified. Equipment: Yes Installation and use of an insulin infusion pump and other necessary equipment. Supplies: Yes Not specified.

Education: Yes Not specified. Services: Yes Self-management programs. Copayments/Deductibles Coverage required under this paragraph shall be subject to the same exclusions, limitations, deductibles and coinsurance provisions of the plan as other covered expenses, except that insulin infusion pump coverage may be limited to purchase of one pump per year, and the plan may require the covered person to use a pump for 30 days before purchase.

Special Features and Issues N/AStatute Web Linkhttp://www.legis.state.wi.us/2001/data/SB-250.pdf Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered** Covered Syringe Combinations: Covered** Covered Blood Glucose Strips: Covered** Covered Notes: As of July 1, 1998, Medicare covers a home glucose monitor, lancets for drawing blood, reagent strips and other supplies necessary for proper use of the glucometer for all diabetics.

Before July 1, 1998, these benefits were available to insulin-dependent diabetics only. Also as of July 1, 1998, Medicare provides coverage for diabetes self-management training furnished in non-hospital-based programs. **Covered as durable medical supplies. Diabetes Prevention and Control Programs Wisconsin Diabetes Prevention & Control Program, Wisconsin Department of Health Services.

http://dhs.wisconsin.gov/health/diabetes/Wyoming Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance522,830 300 4,000 10,000 6,000 4,000 24,300 447,000State Laws and Regulations WY ST §26-18-103: General requirements for policies; WY ST §26-19-107: Group disability and blanket insurance standard provisions; exceptions; WY ST §26-20-201: Diabetes coverage.

Date enacted: 2001. Insurance Policies Required to Provide Coverage All individual and group health insurance policies that provide coverage on an expense-incurred basis; individual and group service or indemnity contracts issued by any insurer including any nonprofit corporation; and individual and group service contracts issued by a health maintenance organization (HMO) that provide coverage.

People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin using diabetes If prescribed by a health care professional legally authorized to prescribe such items under law Benefits Required Medication: N/ANot mentioned.

Equipment and Supplies: Yes Not specified. Education: Yes Medical nutrition therapy included. Services: Yes Outpatient self-management training. Copayments/Deductibles The benefits provided shall be subject to the same annual deductibles or coinsurance established for all other covered benefits within a given policy. Special Features and Issues N/AStatute Web Linkhttp://legisweb.state.wy.us/statutes/statutes.aspx?file=titles/Title26/Title26.htm Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: Disease Management/Patient Education Program includes diabetes. Program administrator: APS Healthcare. Diabetes Prevention and Control Programs Wyoming Diabetes Prevention & Control Program, Wyoming Department of Health.

http://wdh.state.wy.us/PHSD/DIABETES/index.html District of Columbia Number of Residents with Diabetes by Age Group State Population Age Birth to 19 Age 20 to 44 Age 45 to 64 Age 65 to 74 Age 75+ Total State Population with Diabetes Number of People Covered by Health Insurance588,292 300 4,000 16,000 9,000 6,000 35,300 526,000State Laws and Regulations DC CODE §31-3001: Definitions; DC CODE §31-3002: Payable Benefits; DC CODE §31-3003: Nondiscrimination; DC CODE §31-3004: Applicability.

Date enacted: 2000. Insurance Policies Required to Provide Coverage “Health benefit plan” means an accident and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by a multiple employer welfare arrangement, or plan provided by another benefit arrangement. People Covered by Insurance Mandates Insulin-dependent diabetes Insulin-using diabetes Gestational diabetes Non-insulin-using diabetes Benefits Required Medication: N/ANot mentioned.

Equipment and Supplies: Yes Not specified. Education: Yes Medical nutritional therapy included, for treatment of diabetes if prescribed by a health care professional legally authorized to prescribe such item.

Services: Yes Outpatient self-management training. Copayments/Deductibles Not specified. Special Features and Issues N/AStatute Web Linkhttp://www.michie.com/dc/lpext.dll?f=templates&fn=main-h.htm&cp =Public Programs Medicaid CHIPPrescribed Insulin: Covered Covered Disposable Needles: Covered Covered Syringe Combinations: Covered Covered Blood Glucose Strips: Covered Covered Notes: N/ADiabetes Prevention and Control Programs DC Diabetes Prevention & Control Program, D. C. Department of Health.

Visit the website. Puerto Rico, the U. S. Virgin Islands and Guam have not enacted statutes regarding insurance coverage for diabetes sufferers. Based on the Medicaid coverage information available from the Centers for Medicare and Medicaid Services and Medicaid benefits coverage compiled by the National Pharmaceutical Council, no information was available on Medicaid coverage for diabetes in these territories.

Puerto Rico, U. S. Virgin Islands and Guam Territory Population0-19 year olds with diabetes.18-44 year olds with diabetes45-64 year olds with diabetes65-74 year olds with diabetes75+ year olds with diabetes Total Population with Diabetes Puerto Rico3,942,3752,20042,000155,00074,00056,000330,200U.

S. Virgin Islands109,840110021000+3,00010001000+6100Guam175,87731004Guam Statistics on Diabetes 5Population0-19 year olds with diabetes25-34 year olds with diabetes35-44 year olds with diabetes45-54 year olds with diabetes Total Population with Diabetes6Number of People with Health Insurance175,8775100720081,0002,00016,000144,000Additional Resources Policymaker Resources American Diabetes Association Health Insurance in Your State. Alexandria, VA, 2010; www.diabetes.org/advocacy-and-legalresources/insurance/overview.jsp. Centers for Disease Control and Prevention. CDC's Diabetes Program - Data and Trends. Atlanta, Ga.: CDC, 2011; http://apps.nccd.cdc.gov/DDTSTRS/default.aspx.

Islets of Hope. IOH - State laws that affect diabetics. : Upland, Calif.: IOH, 2008; www.isletsofhope.com/diabetes/state-law/main_1.html. National Pharmaceutical Council. Pharmaceutical Benefits Under State Medical Assistance Programs, 2007.: Reston, Va.: NPC, 2007; Print version, page 4-33. http://www.scribd.com/doc/8417428/Pharmaceutical-Benefits-Under-State-Medical-Assistance-Programs-2007 . U. S. Census Bureau. Health Insurance Coverage Status by State for All People: 2009.: Washington D. C. : U. S. Census Bureau, 2010; http://www.census.gov/hhes/www/cpstables/032010/health/h06_000.htm.

U. S. Census Bureau. United States by States and Puerto Rico- Population Estimates. : Washington D. C.: U. S. Census Bureau, 2009; http://factfinder.census.gov/servlet/GCTTable?_bm=y&-state=gct&-ds_name=PEP_2009_EST&-_box_head_nbr=GCT-T1&-mt_name=&-redo Log=true&-_caller=geoselect&-geo_id=&-format=US-40&-_lang=en. West Law. Mandated Coverage For Diabetes Supplies, Education, and Self-Management. Thomson West Publishers, Eagan, Minn.: 2007.

Consumer Resources The National Changing Diabetes® Program (NCDP) brings together innovators in diabetes education, treatment, reimbursement and policy to shift attitudes and change the way patients and health care professionals think about diabetes. Launched in 2005, the National Changing Diabetes® Program is a plan of action - operating on multiple fronts - that aims to improve diabetes outcomes which in turn will have a positive impact on the lives of countless Americans.

Our vision is to change diabetes - to improve lives by causing change in the US system of health care to dramatically advance the prevention, care and management of diabetes.

Private Sector Initiatives United Health Care Example: United Health Care is now using health savings accounts (HSAs) and health reimbursement arrangements (HRAs) to do something innovative: aligning health incentives with economic incentives. For diabetics, the program works like this. Deductibles and copayments are reduced to zero for four classes of medications, certain supplies and some office visits.

Patients are further prodded by an online tracking and reminder system. Patients who comply with their treatment regimes are rewarded with an additional contribution to their health account of up to $1,000 a year. Details online: http://healthaffairs.org/blog/2009/02/12/patient-power-for-chronic-illness, 2/09. Related Resources Diabetes Public Health Resource - Information for the public and professionals about diabetes, including research, statistics and educational publications.

Treating Diabetes (insulin and oral medication use) - CDC, 2007. Duration of Diabetes Among Adults Aged 18-79 Years, 2008 - CDC, 2010. Hospitalization for Diabetes - In 2006, there were 584,000 hospital discharges for diabetes as the first-listed diagnosis (Centers for Disease Control). National Diabetes Education Program - NDEP is a partnership of the National Institutes of Health, the Centers for Disease Control and Prevention, and more than 200 public and private organizations. The American Diabetes Association - Extensive information about diabetes medical and health issues. Diabetes Care - Consumer and Provider Resources - Novo-Nordisk. Juvenile Diabetes Research Foundation International - Research materials and information on Type 1 (Juvenile). National Changing Diabetes Program (NCDP) - brings together innovators in diabetes education, treatment, reimbursement and policy to shift attitudes and change the way patients and health care professionals think about diabetes. Hosted by Novo-Nordisk, Inc. U. S. Health and Human Services Secretary Tommy Thompson launched a National Diabetes Education Program (NDEP), run by the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC) and the Health Care Financing Administration (HCFA) to help older adults understand that routine self-monitoring of blood sugar levels can help delay or prevent the complications of diabetes. Beginning May 2001, the NDEP is working with HCFA to reach Americans 65 years and older as well as younger people with disabilities who have diabetes with information on the treatment and benefits available for people with Medicare. HHS estimates 4.5 million Medicare beneficiaries have diabetes. Pennsylvania Study of Diabetes Disease Management. Published by the PA HCCCC, May 2002 http://www.phc4.org/reports/FYI/fyi11.htm End Notes and Sources United States Census Bureau. United States by States and Puerto Rico Population Estimates. 2007 Estimate http://factfinder.census.gov/servlet/GCTTable?_bm=y&-geo_id=01000US&-_box_head_nbr=GCT-T1&-ds_name=PEP_2007_EST&-_lang=en&-format=US-9&-_sse=on . The 2007 estimate is used for all the states and territories unless otherwise noted. This figure was calculated using US Census population figures for the birth to 19 year old population. The Centers for Disease Control estimates that 0.2% of 0-19 year olds are diabetic. (www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf). The estimated figure here represents 0.2% of each state's 0-19 year old population. Note as well that the 0-19 year old category overlaps with the next category covering 18 to 44 year olds for two years - 18 year olds and 19 year olds. This overlap was a consequence of using the available diabetes data from the CDC and the population estimates available from the Census Bureau, which were used to calculate the number of diabetics between 0 and 19 years of age. The figure is a 2007 estimate. Centers for Disease Control and Prevention. CDC's Diabetes Program - Data & Trends - Diabetes Surveillance System - Prevalence of Diabetes by State - Numbers (in Thousands) with Diagnosed Diabetes, by Age and State, United States, 1994-2005. Centers for Disease Control and Prevention. www.cdc.gov/diabetes/statistics/prev/state/t Number Total.htm. Note the total state population of individuals with diabetes does not always precisely equal the sum of the number of diabetics for each age range due to rounding done by the CDC in their collection of this data of adult diabetics. This 2005 estimate from CDC is used for all the states and territories unless otherwise noted. United States Census Bureau. Health Insurance Coverage Status by State for All People: 1999 to 2007. 2007 Estimate. www.census.gov/hhes/www/hlthins/historic/hihistt4.xls The National Pharmaceutical Council. Pharmaceutical Benefits Under State Medical Assistance Programs. 2007. http://www.scribd.com/doc/8417428/Pharmaceutical-Benefits-Under-State-Medical-Assistance-Programs-2007The most recent data available for individuals with diabetes in Hawaii is 2004 for all age ranges except the birth to age 19 range. This data is presented here. All other states have 2005 data for the age categories between 18 and 75+ unless noted otherwise. (http://www.cdc.gov/diabetes/statistics/prev/state/t Number Total.htm) accessed 9/10/08. CIA Fact Book Online. https://www.cia.gov/library/publications/the-world-factbook/geos/vq.html. 2008 estimate. This figure was calculated using 2000 US Census population figures for United States Virgin Islands. ; www.census.gov/prod/cen2000/island/VIprofile.pdf. CIA Fact Book Online. https://www.cia.gov/library/publications/the-world-factbook/geos/gq.html. 2008 estimate.2000 estimate. This figure was calculated using 2000 US Census population figures for Guam. ( http://www.census.gov/prod/cen2000/island/VIprofile.pdf ). Unless otherwise noted, the data for Guam are from the Guam Behavioral Risk Factor Surveillance System study of diabetes in Guam residents. The results of this random sampling study have been extrapolated to the larger Guam population to estimate diabetes sufferers in all the age groups except the 0-19-year-old group. The BRFS was used to estimate the number of Guam residents with health insurance. This estimated figure is based on the Guam BRFS finding that 9.2 percent of the population has been diagnosed as diabetic. This estimate does not include the approximately 2.4 percent of the Guam population that is considered either borderline diabetic or at risk of diabetes. CIA Fact Book Online. https://www.cia.gov/library/publications/the-world-factbook/geos/gq.html. 2008 estimate. This figure was calculated using 2000 U. S. Census population figures for Guam; www.census.gov/prod/cen2000/island/VIprofile.pdf Authors: Richard Cauchi, program director, authored the 1999-2008 and 2010 editions and manages NCSL work on health insurance and coverage. Katie Mason authored the 2011 updates. Yeasol Chung provided extensive 2008 research, writing and design for this expanded report. Andrew Thangasamy provided additional research and editing for the 2009 edition. This report is a project of the NCSL Health Program, based in Denver. It will be updated regularly to reflect new laws and state statistics. NCSL gratefully acknowledges Novo-Nordisk for providing financial support for this project. "

on: Durable medical equipment Durable medical equipment used to describe any medical equipment used in the home to aid in a better quality of living. It is a benefit included in most insurances. In some cases certain Medicare benefits, that is, whether Medicare may pay for the item. The item is defined by Title XIX for Medicaid:

Translations for Durable Medical Equipment

"Freebase (0.00 / 0 votes)Rate this definiti

U. S. National Library of Medicine (0.00 / 0 votes)Rate this definition: Durable Medical Equipment Devices which are very resistant to wear and may be used over a long period of time.

They include items such as wheelchairs, hospital beds, artificial limbs, etc. Numerology Chaldean Numerology The numerical value of Durable Medical Equipment in Chaldean Numerology is: 2Pythagorean Numerology The numerical value of Durable Medical Equipment in Pythagorean Numerology is: 5Sample Sentences & Example Usage Joshua Fogel: Ideally, (patients) should get a CPAP machine through their doctor's office or durable medical equipment (DME) company, who will then provide education and ongoing support for the CPAP device and supplies.

Images & Illustrations of Durable Medical Equipment Translations for Durable Medical Equipment From our Multilingual Translation Dictionary耐久性のある医療機器 Japanese Get even more translations for Durable Medical Equipment »Translation Find a translation for the Durable Medical Equipment definition in other languages: Select another language: Discuss these Durable Medical Equipment definitions with the community: Word of the Day Would you like us to send you a FREE new word definition delivered to your inbox daily?

Please enter your email address: Subscribe Citation Use the citation below to add this definition to your bibliography: Style: MLA Chicago APA""Durable Medical Equipment."" Definitions.net. STANDS4 LLC, 2018. Web. 26 Mar. 2018. < https://www.definitions.net/definition/Durable Medical Equipment >. Are we missing a good definition for Durable Medical Equipment? Don't keep it to yourself... Submit Definition "

? Most insurance plans provide coverage for insulin pump therapy and diabetes testing supplies under a Durable Medical Equipment (DME) clause. Pump manufacturers’ insurance departments have the expertise to negotiate approval for payment with your insurance provider.

Financial Concerns About Insulin Pumps

"Uncategorized Financial Concerns About Insulin Pumps February 1, 2006 Barbara Bradley Leave a comment Share this: Many concerns arise when patients consider the costs of insulin pump therapy.

The following are a few of the most frequently asked questions: What is the cost of a pump? About $6,000 is the average price. How much of the cost will my insurance cover

If you have a co-payment, the manufacturer will set up a payment plan, if necessary. Medicare and Medicaid plans also provide coverage, but you should check with the plan administrator in your state.

What is the cost of supplies? Monthly costs for intensive insulin pump management supplies can range from $250 to $500, depending on your insurance plan and on the frequency of site changes. Here are potential costs for 10 set changes per month (every three days): Needle set Approximately $6.90 per set $6990-degree insertion cannula Depending on the brand, $10.83 per set or $13.50 per set $108.30 $13530-degree insertion cannula $11 per set $110Pump syringes $10 per month $37-$46Sterile dressings and skin prep $10 per month Example: box of 50 IV prep wipes Some vendor cash prices can be 30%-50% less than billed list price.

Ask about payment options and discounts. $32 (billed) $16 (cash)Insulin Depends on coverage/co-pay/amount used. Variable Test strips Minimum of four daily multiplied by cost per strip. Approximately .75 to $1.00 per strip.

Usually covered by insurance. $3-$10 per day Prices shown are estimates only. Vendor and manufacturer prices vary and can change at any time. How can we save money on supplies? If you use sites and supplies beyond the recommended limits, consider these costs: How much does a trip to the emergency room or the doctor’s office cost if you develop an abscess?

What is the cost of the antibiotic to treat an infection? What is it worth to avoid the inconvenience of a missed delivery or occlusion alarms or the wait for a replacement pump?

What about tax deductions? Keep all receipts for diabetes supplies and prescriptions. These can add up, and they may be partially deductible as medical expenses.

Even if they are not deductible, you have started a paper trail of medical expenses that might be useful in a future tax year. Talk to the manufacturer’s sales and insurance staff . Don’t let any of the above concerns deter you from seeking a better quality of life, because having a better quality of life is truly priceless.

Share this: Like this: Loading... Related Ask Nadia: Should I get A Therapy Dog Because My Great Niece’s Fluctuating Blood Sugars? April 16, 2017In ""Continuous Glucose Monitoring""Ask Nadia: The History of the Implantable Insulin Pump June 19, 2017In ""Blood Sugar Readings""Medtronic Responds to ""A Miracle Technology for Type 1s: Can It Be Saved? ""May 5, 2011In ""Blog"" "

DME)What durable medical equipment (DME) does Medicare cover? How can I file a complaint? Competitive Bidding Program What areas, equipment and supplies are included? Where and how can I get equipment and supplies? Where can I get equipment and supplies when I travel? How does Medicare's coverage of equipment and supplies work with other insurance? How can I find a Medicare contract supplier?

Durable medical equipment (DME)

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)As with any insurance benefit, things are generally only covered if ""medically necessary"". That said, OTC orthotics are generally never covered. Prescription orthotics (if indicated) are covered by *most* (but not all) insurance payors. Generally falls under the DME or durable medical equipment guidlines. I can't comment on eyeglasses or sunglasses as that is generally an entirely separate policy/issue.

Triathlon Forum

"Triathlon Forum Back To Forum Will my HSA pay for orthotics or sunglasses? Quote | Replysoftrider Dec 12, 07 18:32Post #1 of 3 (5902 views)I have a health savings account, the type that rolls over from year to year and its pre tax money.

I was wondering if I could use the debit card they gave me (about $300 worth of savings) to buy over the counter orthotics (Sole Footbed) or sunglasses from my optometrist. I am more interested in finding out if I could buy orthotics because I need some foot support in my various shoes (work, running, cycling shoes). I could not find any mention of foot orthotics in the IRS 502 but it seems like it would be covered.

Any help would be appreciated, it could save me some bucks. Thanks Re: Will my HSA pay for orthotics or sunglasses? [softrider] [ In reply to ] Quote | Replyrroof Dec 12, 07 18:40Post #2 of 3 (5895 views

____________________________________ Fatigue is biochemical, not biomechanical. - Andrew Coggan, Ph DRe: Will my HSA pay for orthotics or sunglasses? [softrider] [ In reply to ] Quote | Replyejohns3992Dec 12, 07 19:29Post #3 of 3 (5865 views)I bought two pair of Rudy Project with the RX inserts from my eye doctor and HSA reimbursed me promptly. Back To Forum "