This article is general information, not medical, insurance, legal or financial advice. What is covered depends on the country, state, insurer, employer and plan, and the details in your own policy control.
What “durable medical equipment” means
Many plans cover medical devices under a category usually called durable medical equipment, or DME. Definitions differ by plan, but the idea is generally that an item qualifies if it:
- is meant to be used repeatedly and can withstand that use
- is primarily used for a medical purpose rather than for general convenience or comfort
- is useful mainly to someone who is ill or injured
- is appropriate to use at home
Examples commonly considered in this category include wheelchairs, walkers, crutches, hospital beds, oxygen equipment, nebulizers and certain monitors or breathing devices. Prosthetics, orthotics and supplies that go with equipment, such as tubing or testing supplies, are often handled in related categories with their own rules. Items like a standard exercise machine or a home air purifier are commonly treated as general-purpose and excluded, though practice varies.
Implanted devices such as a pacemaker or joint implant are typically billed as part of a procedure and hospital stay, so they follow surgical and inpatient rules rather than DME rules.
What a plan typically requires first
Plans generally want to see that the device is needed for a medical reason and prescribed by a clinician. Common requirements include:
- A prescription or written order. It usually must come from a treating doctor or other qualified practitioner and state the device and the diagnosis.
- Supporting documentation. The plan may ask for clinical notes showing why the device is needed, sometimes called a statement or letter of medical necessity. This is the same concept explained in the article on medical necessity.
- Prior authorization. Higher-cost items are often on a list of devices that need approval before you obtain them. Approval requests are usually submitted by the doctor’s office or the supplier.
- An in-network supplier. Plans often require that the equipment come from a supplier in the plan’s provider networks. Buying from a store that is not in network may mean no payment or a reduced one.
- A face-to-face visit or evaluation. For some devices, plans want a recent visit documenting the need.
Missing a step is a leading reason for claim problems with devices, so it is worth asking the plan which steps apply before you pay for anything.
Rental, purchase and replacement
Plans often have rules about how you obtain the equipment. Some items are rented for a period, and the plan may pay in monthly installments and later treat the item as purchased. Other items are bought outright. Plans may allow the cheaper option, for instance a basic model when a more elaborate one was requested, and may expect you to pay the difference for upgrades.
Replacement and repair rules often exist as well. A plan may allow replacement only after a number of years, or when the item is no longer working and cannot be repaired, or when a patient’s condition changes. Loss or damage may not be covered. Rules for children can be different because they outgrow equipment.
Costs you may still pay
Even when a device is covered, cost-sharing usually applies. Depending on the plan, you may pay the deductible, then a share of the plan’s allowed amount as coinsurance, or a copay. Some plans apply a separate limit to equipment or cap the amount per year. Items beyond the covered type, or beyond annual limits, may be your responsibility. Unlike many routine services, equipment charges may count toward your out-of-pocket maximum only if the item is a covered service obtained under the plan’s rules.
If the plan does not cover the device, other options may be worth exploring, such as paying with a health savings account or flexible spending account where the item is among eligible medical expenses, or looking at the broader subject of paying for equipment. Eligibility under those accounts has its own rules.
Related benefits
Devices that cross categories can be confusing. Hearing aid coverage, for example, is commonly treated separately from DME and may be limited or excluded. Contact lenses and glasses may fall under vision insurance. Home oxygen or a hospital bed may be part of in-home care benefits. Insulin pumps and glucose monitors may be handled partly as devices and partly as supplies, sometimes through the pharmacy benefit. Check which part of the plan governs the specific item.
Questions to ask before getting a device
- Is this device covered, and under which benefit category?
- Is prior approval needed, and who submits it?
- Which suppliers are in network?
- Is it a rental or a purchase, and for how long?
- What will I owe, and does a limit apply?
- How are repairs and replacement handled?
Take notes of who answered and the reference number given, since an answer by phone is not a guarantee of payment.
If a claim is denied
Read the denial letter for the stated reason. Frequent ones include missing prior authorization, a supplier out of network, insufficient documentation, or the plan deciding the item is not medically necessary or is excluded. Sometimes a supplier or doctor can fix a paperwork gap and resubmit. If not, a claim appeal may follow, and some systems offer external review afterward. Keep your order, notes, approvals and correspondence together as dispute documentation. Results vary and cannot be promised.