This is general information, not insurance, medical, legal or financial advice. What gets covered, and how, varies by country, plan and employer. Your policy and insurer have the final word.
Whether a given kind of device is covered at all is a question for your policy. This article focuses on the process: how to move from “my doctor says I need this” to “the plan has paid its share.”
Understand the usual categories
Plans often group devices and equipment into a few types, and the rules differ among them:
- Durable equipment, such as mobility aids, home oxygen equipment or hospital-style beds, which is often reusable and sometimes rented
- Prosthetics and orthotics, such as artificial limbs or braces
- Supplies, such as testing strips or wound care items, which are used up and reordered regularly
- Implanted devices, which are generally handled as part of a surgery or hospital stay rather than as a separate purchase
Knowing which category your item falls into helps, because each may follow a different approval and billing route.
Step 1: Get a prescription or order
Insurers usually want evidence that a device is needed for a medical reason. That typically begins with a prescription or written order from a licensed clinician. The order often needs to name the item, and the supporting medical notes should describe the condition and why the item is appropriate.
Ask your clinician’s office to include details your plan is likely to look for, such as the diagnosis, how long the item will be needed and how it will be used. Plans commonly judge these requests by whether the item is medically necessary, so clear notes make a difference. A vague order is a frequent cause of delay.
Step 2: Check coverage and limits
Before you order, contact your insurer and ask:
- Is this item or category covered under my plan?
- Is there a list of approved models or brands?
- Do I pay a copay, coinsurance or the full cost until my deductible is met?
- Does the plan rent, buy, or both? Are repairs and replacement covered?
- Is there a limit on how often a replacement is allowed?
Some plans place restrictions on frequency, such as how often a similar item can be replaced. These details are in your policy documents, but a call can make them concrete.
Step 3: Ask about preauthorization
Many plans require approval before they pay for more expensive devices or for rentals. This is commonly called prior authorization, or preauthorization. The request is usually submitted by the prescribing clinician or the supplier, and the insurer then decides whether the item meets its criteria.
Do not assume the supplier has handled it. Ask: “Has approval been requested? What is the reference number? What is the decision and when will it be sent?” If approval is denied, the decision letter should explain why and how to ask for a review.
Skipping a required approval can mean the claim is refused even when the device itself would otherwise have been covered.
Step 4: Choose the supplier carefully
Where you buy matters. Plans often require equipment to come from a supplier in their network, and buying elsewhere may mean reduced payment or none. Ask your insurer for an in-network supplier list, or ask the supplier directly whether they work with your plan and then verify with the insurer.
Compare a few points before committing:
- Does the supplier bill the insurer directly, or must you pay and claim back?
- Who handles setup, training, repairs and returns?
- What is the supplier’s policy if the plan later refuses payment?
- Will you be asked to sign a form accepting responsibility for costs?
Read anything you sign. If a supplier says an item is “covered,” ask for the amount you are expected to pay in writing where possible.
Step 5: Keep paperwork
Save the prescription, approval letters, supplier invoices, delivery receipts and every explanation of benefits you receive. If the device is rented, keep track of rental periods, because insurers sometimes stop payment after a set period or after the equipment is judged to be no longer needed, and may ask for updated medical notes to continue.
Using savings accounts
If your plan offers a health savings account or flexible spending account, some equipment may be an eligible expense, particularly when a clinician has prescribed it. Eligibility rules vary, and some items need a letter from a clinician. Check the account’s list of eligible medical expenses and keep your receipts.
If payment is refused
Start with the denial letter and look for the stated reason. Common causes include missing paperwork, a required approval that was not obtained, a supplier outside the network, or a judgment that the item does not meet criteria. Missing documents can often be supplied. For a coverage disagreement, ask about your insurer’s appeal process, and consider asking your clinician for a stronger letter of support. Outcomes are not guaranteed.
A short checklist
- Get a detailed prescription and notes.
- Confirm coverage, limits and cost sharing.
- Make sure approval has been requested and granted.
- Use an in-network supplier where required.
- Keep every document.
- Appeal promptly if you disagree with a decision.