In most cases, compression stockings and compression garments are not covered by Medicare even with a prescription. But, compression stockings and garments are commonly covered by secondary or supplemental insurance plans when submitted with appropriate documentation after the Medicare claim denial. There is a Medicare exception to accept a compression stockings claim when a patient has a diagnosis of a current venous stasis ulcer. This does require specific documentation and a prescription for graduated compression stockings or adjustable compression wraps with compression levels of 30-40 mmHg or 40-50 mmHG.
Many commercial insurance plans that are provided through an employer or purchased through various state offerings for the Affordable Care Act are acceptable secondary insurance. The insurance coverage can vary from each state, insurance provider, and even within each plan. Check your policy for coverage of Durable Medical Equipment and make note of the annual deductibles that are presented. Lastly, note that insurance coverage can be determined by the diagnosis or ICD-10 code a healthcare provider documents and prescribes. Some plans may cover venous health-related diagnoses such as varicose veins, chronic venous insufficiency, or DVTs, while others may cover a lymphedema diagnosis. Nearly all plans will cover the diagnosis of open venous leg ulcers for compression stockings and adjustable compression wraps of 30-40 mmHG and 40-50 mmHg.
Are orthopedic bracing products covered by Medicare or health insurance?
Most orthopedic bracing that provides structural support with a rigid material, like aluminum or carbon, or that provide functionality and deemed medically necessary are generally covered by Medicare and most commercial health insurance plans. To qualify, the orthopedic brace must be accepted by Medicare and given a PDAC letter of approval. Products must be fit and billed through an approved DME (durable medical equipment) provider. In most cases, Medicare or the insurance carrier may only cover a portion of the brace, so be prepared for some form of co-payment.
Medicare or commercial insurance coverage for supports for knee, ankle, Achilles, elbow, and wrist that are categorized for prophylactic use can be covered at times. Orthopedic supports are commonly used to provide pain relief in joints that have previously been surgically repaired or to provide added stability during activity.
Are compression pumps covered by Medicare or health insurance?
Approved Medicare pneumatic compression devices are a covered benefit with a diagnosis of lymphedema or chronic venous insufficiency with an open venous leg ulcer that has been treated for at least 6 months. Medicare requires a prescription as well as some specific clinical notations from a physician prior to authorization of the compression pump. Most commercial health care insurance providers follow these same Medicare guidelines.
Compression pumps must be billed and set up by an approved Medicare DME who can determine if a patient qualifies for insurance coverage. In many cases, the entire cost of the compression pump is not covered 100% and the patient may be responsible for a co-pay.
How can I find out if my medical product is covered by my health insurance?
First, it will be important to have a clear diagnosis with a prescription from your health care provider to properly obtain the coverage information. Your healthcare provider may have some preliminary information but will likely defer to your carrier.
Check your insurance plan benefits for DME coverage. Make note of any deductibles that may need to be met prior to the insurance activating to cover these costs. There may also be co-pays based on the product category and type of insurance. Your insurance carrier and your local medi dealer can likely provide more detailed guidance based on your specific situation.
What documentation is needed to submit a health insurance claim for medical products?
In most cases, a DME (durable medical equipment) provider will need the following information to determine coverage or submit a claim:
- Beneficiary name/ policy #
- Prescription with diagnosis (ICD-10 code)/Certificate of Medical necessity
- Product Description / HCPCS product code
- Quantity/ Duration of use
- Refills
