Medicare Coverage for Prosthetics and Orthotics

 

Prosthetics:

Additional Prostheses other than those listed below may be covered by Medicare. Talk to your supplier for specific details or questions regarding those items.

Breast Prostheses

• Breast Prostheses are covered after a radical mastectomy. Medicare will cover:
  • One silicone prosthesis every two years or a mastectomy form every six months.
  • As an alternative, Medicare can cover a nipple prosthesis every three months.
  • Mastectomy bras are covered as needed, but not on an automatic basis.
• There is no coverage for replacement prostheses due to wear and tear before the specified time frames. However, Medicare will cover replacement of these items due to:
  • Loss
  • Irreparable damage, or
  • Change in medical condition (e.g. significant weight gain/loss)
• You are allowed only one prosthesis per affected side, others will be denied as not medically necessary even if attempting asymmetry (an Advance Beneficiary Notice should be provided in this circumstance).
• Mastectomy sleeves which are used to control swelling are not covered in the home setting because they do not meet Medicare’s definition of prosthesis; however, it is possible that they may be covered under the hospital per diem if you request one during your hospital stay.
• A mastectomy bra is covered if the pocket of the bra is used to hold a covered prosthesis or mastectomy form.

Eye Prostheses

• Eye prostheses are covered by Medicare if you have an absence or shrinkage of an eye due to birth defect, trauma or surgical removal.
• Medicare will also cover polishing and resurfacing of the prosthesis twice annually.
• Medicare will cover a one-time enlargement or reduction of your prosthesis when medically necessary.  Speak with your physician or healthcare provider if there is a medical need to have your prosthesis resized beyond the one time allowance.
• Your prosthesis may be eligible for replacement after five years under the Medicare benefit, talk with your supplier for details
• Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare cannot make payment for those products to you or your supplier.  So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

Facial Prostheses

• Facial prostheses are covered by Medicare if you have a loss or absence of facial tissue due to disease, trauma, surgery or birth defect.
• Facial prostheses can replace all or part of the face and can include:
  • Nasal prosthesis – removable superficial prosthesis which restores all or part of the nose and may include the nasal septum.
  • Mid-facial prosthesis – removable superficial prosthesis which restores part or all of the nose and significant adjacent facial tissue/structures, but does not include the eye orbit or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek, upper lip, or forehead.
  • Orbital prosthesis - removable superficial prosthesis, which restores the eyelids and the hard and soft tissue of the orbit. It may also include the eyebrow.
  • Upper facial prosthesis - removable superficial prosthesis, which restores the orbit and significant adjacent facial tissue/structures, but does not include the nose or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek or forehead. This code does not include the eye prosthesis. 
  • Hemi-facial prosthesis - removable superficial prosthesis, which restores part or all of the nose and the orbit plus significant adjacent facial tissue/structures, but does not include any intraoral maxillary component. This code does not include the eye prosthesis.
  • Auricular prosthesis - removable superficial prosthesis, which restores all or part of the ear.
  • Partial facial prosthesis - removable superficial prosthesis which restores a portion of the face but does not specifically involve the nose, orbit, or ear.
  • Nasal septal prosthesis - removable prosthesis, which occludes a hole in the nasal septum but does not include superficial nasal tissue.
• Medicare will not cover skin care products that are related to the use of the prosthesis including cosmetics, skin cream, cleansers, etc.
• Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare cannot make payment for those products to you or your supplier.  So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
• Your physician and prosthetist will best determine the type of prosthesis that is necessary for your condition. If you would prefer a prosthesis that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the item that you want.

Glasses

• Medicare covers one complete pair of glasses, after the last cataract surgery with intra-ocular lens replacement. The Medicare benefit includes a frame and two lenses.  As an alternative, a pair of contact lenses can be covered in lieu of glasses.
• Medicare beneficiaries that have a condition called aphakia (patients who are born without an intraocular lens, or who have had the lens removed and not replaced), are eligible for glasses, and/or contacts as often as is medically necessary.
• When specifically prescribed for a medical condition documented in your medical chart, Medicare may also cover additional medically necessary features such as tint, anti-reflective coating, and/or UV.

Lower Limb Prostheses

• Lower Limb Prostheses include those designed to replace feet, knees, ankles, hips or sockets and are covered when:
  • You will reach or maintain a desired functional state within a reasonable time frame; and
  • You are motivated to walk.
• Medicare coverage is considered based on an assessment of your potential functional abilities as determined by your physician and prosthetist. To determine your functional level, your physician and prosthetist will consider:
  • Your past history (including the use of prior prostheses, if applicable),
  • Your current condition including the status of the residual limb, as well as any other medical problems you may have, and
  • Your desire to walk.
• Lower Limb Prostheses can be custom fabricated for you or provided off the shelf and custom fitted to address your individual needs. Custom fabricated items are created specifically to suit your individual needs and tend to be more expensive. Off the shelf prostheses can be bought “as is” and then customized for an individual fit. 
• Your physician and prosthetist will best determine the type of prosthesis that is necessary for your condition. If you would prefer a prosthesis that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the item that you want.

Non-covered items (partial listing)

• Adult diapers
• Bathroom safety equipment
• Hearing aides
• Syringes/needles
• Van lifts or ramps
• Exercise equipment
• Humidifiers/Air Purifiers
• Raised toilet seats
• Massage devices
• Stairlifts
• Emergency communicators
• Low vision aids
• Grab bars
• Elastic garments  

Ostomy Supplies

• Ostomy supplies are covered for people with a:
  • colostomy,
  • ileostomy, or
  • urostomy
• You may obtain up to a three month’s supply of wafers, pouches, paste and other necessary items as needed.
• You must have nearly depleted the supplies on hand to be eligible for additional product.

Parenteral and Enteral Therapy**

• Parenteral therapy requires all or part of the gastrointestinal tract to be missing. Nutritional formulas are delivered through a vein.
• Enteral therapy is covered if you cannot swallow or take food orally. Nutrition must be delivered through a tube directly into the gastrointestinal tract.
• Medicare will not pay for nutritional formulas that are taken orally.
• Specialty nutrition/formulas can be covered if you have unique nutritional needs or specific disease conditions which are well documented in your physician’s or healthcare provider’s records.  In most cases, you may have to try standard formulas and document that they are unsuccessful before Medicare will consider the specialty nutrition.
• You must have nearly depleted the supplies on hand to be eligible for additional product.

** Some or all of the products in this category may be subject to competitive bidding depending on where you live.  Ask your supplier for details.

Therapeutic Shoes

• Special therapeutic shoes, inserts and modifications can be covered for diabetic patients with the following foot conditions:
  • previous amputation of a foot or partial foot
  • history of foot ulceration or pre-ulcerative calluses
  • peripheral neuropathy with callus formation
  • foot deformity
  • poor circulation in either foot
• You must have an office visit with your physician or healthcare provider within six months of receiving new shoes to discuss and document your diabetes management and why you need these special shoes.  This office visit must be repeated each time you wish to obtain replacement shoes.
• Only a physician treating your diabetes can certify your diabetic condition and complications that require specialty shoes. 
• Your healthcare practitioner or a podiatrist may further evaluate your feet and order the shoes.
• When providing you with shoes, your supplier must perform an in-person evaluation of your foot/feet, and they must verify that your shoes fit properly.
• Newly established requirements of the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a compliant written order.
• Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider. If the equipment is subject to these special rules, your supplier cannot get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier when a compliant order is not secured before delivery.  So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.

Urological Supplies

• Urinary catheters and external urinary collection devices are covered to drain or collect urine if you have permanent urinary incontinence or permanent urinary retention. Permanent incontinence and retention are defined as a condition that is not expected to be medically or surgically corrected within 3 months.
• A maximum of six catheters may be used per day (up to 200 per month), unless it is determined that a higher number is medically necessary by your physician or healthcare provider, and these unique circumstances are specifically documented in your medical records.
• When at home, you may receive up to a 3-month supply at one time.
• You must have nearly depleted the supplies on hand to be eligible for additional products.

Vacuum Erection Devices (VEDs)

• Vacuum Erection Devices (VEDs) are no longer covered by Medicare for the treatment of erectile dysfunction.
• As of July 1, 2015, the Achieving a Better Life Experience (ABLE) Act of 2014 mandated that Medicare discontinue coverage of these devices to mirror the non-coverage policies of the Medicare Part D program for erectile medication.

Orthotics:

Ankle-Foot Orthoses (Braces)

• Ankle-Foot Braces are covered for patients that:
  • are able to walk,
  • need the ankle or foot to be stabilized due to a weakness or deformity, and
  • have the potential to benefit functionally from the use of the brace to do more than could be accomplished without a brace.
• In order for Medicare to cover an ankle-foot brace, you must have one of the above conditions and also have undergone a face-to-face visit with your physician to examine your need for the brace.
• Ankle-Foot Braces can be Custom Fitted or provided Off-the-Shelf.
  • Custom Fitted braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require fitting by a certified orthotist, and
    • require substantial modification at the time of the fitting to ensure a proper fit.
  • Off-the-Shelf braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require minimal adjustment by you as the beneficiary for a proper fit, and
    • do not require a certified orthotist to ensure the best possible fit.
• Not all products that fall within this category are eligible for Medicare payment. For an Ankle-Foot Brace to be covered by Medicare, the condition/injury must also qualify. Medicare does not pay for braces used primarily for comfort or prevention purposes.
•  Your physician will best determine the type of brace that is necessary to treat your condition.  If you would prefer a brace that has features above and beyond what you medically need, (such as warmth, circulation support, additional comfort features, etc.) you may be asked to complete an Advanced Beneficiary Notice and pay out of pocket for the brace that you want.

Arm Supports and Slings

• Arm Support and Slings are generally made of cloth-like material and therefore do not meet the definition of a brace. These items are not payable under the Durable Medical Equipment benefit of your Medicare policy.  However, these items are billable by your physician when incident to an office visit and likely can be obtained directly from your physician.

Clavicle/Shoulder Orthoses (Braces)

• Clavicle/Shoulder braces are covered for patients that need:
  • stabilization of the clavicle or shoulder because of a weakness or deformity,
  • to restrict movement of the clavicle or shoulder due to injury or disease, or
  • to limit movement during recovery from a surgical procedure on the clavicle or shoulder.
• In order for Medicare to cover a clavicle/shoulder brace, you must meet one of the above criteria and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit from its use. 
• Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
• Clavicle/Shoulder braces can be Custom Fitted or provided Off-the-Shelf.
  • Custom Fitted braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require fitting by a certified orthotist, and
    • require substantial modification at the time of the fitting to ensure a proper fit.
  • Off-the-Shelf braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require minimal adjustment by you as the beneficiary for a proper fit, and
    • do not require a certified orthotist to ensure the best possible fit.

Elbow Orthoses (Braces)

• Elbow braces are covered for patients that need:
  • Stabilization of the elbow because of a weakness or deformity,
  • To restrict movement of the elbow joint due to an injury or disease, or
  • to limit movement during recovery from a surgical procedure on the elbow.
• In order for Medicare to cover an elbow brace, you must meet one of the above criteria and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit from its use. 
• Elbow braces can be very basic or have additional features. Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
• Elbow braces can be Custom Fitted or provided Off-the-Shelf.
  • Custom Fitted braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require fitting by a certified orthotist, and
    • require substantial modification at the time of the fitting to ensure a proper fit.
  • Off-the-Shelf braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require minimal adjustment by you as the beneficiary for a proper fit, and
    • do not require a certified orthotist to ensure the best possible fit.

Knee Orthoses (Braces)

• Knee braces are covered for patients that:
  • are able to walk;
  • require the knee to be stabilized because of a weakness or deformity of the knee,
  • had a recent injury to the knee, or
  • had a recent surgical procedure on the knee such as a knee joint replacement.
• In order for Medicare to cover payment for a knee brace, you must have one of the above conditions and also have undergone a face-to-face visit with your physician to examine your need for the brace.
• Knee braces can be very basic or have additional features such as Velcro straps, flexible support joints or additional padding for comfort.
• Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
• Knee braces can be Custom Fitted or provided Off-the-Shelf.
  • Custom Fitted braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require fitting by a certified orthotist, and
    • require substantial modification at the time of the fitting to ensure a proper fit.
  • Off-the-Shelf braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require minimal adjustment by you as the beneficiary for a proper fit, and
    • do not require a certified orthotist to ensure the best possible fit.
• Knee braces should be expected to last 1-2 years, depending on the type of brace being prescribed.

Knee-Ankle-Foot Orthoses (Braces)

• Knee-Ankle-Foot Braces are covered for patients that:
  • are able to walk,
  • have a weakness or deformity of the foot and ankle and need additional stability for the knee, and
  • have the potential to benefit functionally from the use of the brace.
• In order for Medicare to provide payment for a Knee-Ankle-Foot brace, you must have one of the above conditions and also have undergone a face-to-face visit with your physician to examine your need for the brace.
• Knee-Ankle-Foot Braces can be Custom Fitted or provided Off-the-Shelf.
  • Custom Fitted braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require fitting by a certified orthotist, and
    • require substantial modification at the time of the fitting to ensure a proper fit.
  • Off-the-Shelf braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require minimal adjustment by you as the beneficiary for a proper fit, and
    • do not require a certified orthotist to ensure the best possible fit.
• Not all products that fall within this category are eligible for Medicare payment. For a Knee- Ankle-Foot Brace to be covered by Medicare the condition it is being used to treat must qualify.
• Your physician will best determine the type of brace that is necessary to treat your condition.  If you would prefer a brace that has features above and beyond what you medically need, (such as warmth, circulation support, additional comfort features, etc.) you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.

Cervical  Orthoses (Neck Braces)

• Neck braces are covered for patients that need:
  • stabilization because of a weakness or deformity of the neck,
  • to restrict movement of the neck due to an injury or disease, or
  • to limit movement during recovery from a surgical procedure on the neck.
• In order for Medicare to cover payment for a neck brace you must meet one of the above criteria and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit functionally from its use.  
• Neck braces can be very basic or have additional features.
• Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
• Neck braces can be Custom Fitted or provided Off-the-Shelf.
  • Custom Fitted braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require fitting by a certified orthotist, and
    • require substantial modification at the time of the fitting to ensure a proper fit.
  • Off-the-Shelf braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require minimal adjustment by you as the beneficiary for a proper fit, and
    • do not require a certified orthotist to ensure the best possible fit.

Orthopedic Shoes

• Orthopedic shoes are covered when it is necessary to attach the shoe(s) to a leg brace.
• Medicare will only pay for the shoe(s) attached to the leg brace(s).
• Medicare will not pay for matching shoes or for shoes that are needed for purposes other than diabetes or leg braces.

Spinal Orthoses (Back Braces)

• Back braces are covered:
  • When it is medically necessary to reduce pain by restricting upper body movement, or
  • to aid in the healing process after injury or a surgical procedure, or
  • to support weak, spinal muscles or a deformed spine
• In order for Medicare to provide payment for a Back brace, you must have one of the above conditions and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit functionally from its use.
• Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
• In order for a back brace to be payable by Medicare it must be made primarily of non-elastic material such as canvas, cotton, nylon etc. or have a rigid posterior panel.
• Back braces that are primarily made of elastic material will not be covered under the Medicare program. These items do not meet the definition of a brace as they are not rigid or semi-rigid and Medicare will not pay for these braces.

Wrist and Forearm Orthoses (Braces)

• Wrist and Forearm braces are covered for patients that need:
  • stabilization of the wrist or forearm because of a weakness or deformity,
  • to restrict movement of the wrist or forearm due to an injury or disease, or
  • to limit movement during recovery from a surgical procedure on the wrist or forearm  (such as a joint replacement).
• In order for Medicare to cover payment for a wrist or forearm brace, you must meet one of the above criteria and also have undergone a face-to-face visit with your physician to examine and document your need for the brace and your ability to benefit functionally from its use.
• Wrist or forearm braces can be very basic or have additional features.
• Your physician will best determine the type of brace that is necessary to treat your condition. If you would prefer a brace that has features above and beyond what you medically need, you may be asked to complete an Advanced Beneficiary Notice and pay out-of-pocket for the brace that you want.
• Wrist and forearm braces can be Custom Fitted or provided Off-the-Shelf.
  • Custom Fitted braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require fitting by a certified orthotist, and
    • require substantial modification at the time of the fitting to ensure a proper fit.
  • Off-the-Shelf braces are manufactured devices that:
    • may be supplied as a kit that requires some assembly,
    • require minimal adjustment by you as the beneficiary for a proper fit, and
    • do not require a certified orthotist to ensure the best possible fit.