Durable Medical Equipment:

Regional Carriers' Coverage Criteria Are Consistent with Medicare Law

HEHS-95-185: Published: Sep 19, 1995. Publicly Released: Sep 19, 1995.

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Pursuant to a congressional request, GAO determined whether regional carrier coverage criteria for durable medical equipment and supplies is consistent with Medicare law, focusing on: (1) the national Medicare requirements and the regional carriers' coverage criteria; and (2) how the criteria have been applied to claims.

GAO found that: (1) the final criteria adopted by the regional carriers are consistent in all material respects with Medicare's national coverage criteria and Medicare law; (2) in 1994, the regional carriers approved durable medical equipment, prostheses, orthoses, and supplies (DMEPOS) claims for disabled Medicare beneficiaries at a similar rate as for aged beneficiaries, and there was no apparent difference in the application of the criteria between disabled and aged Medicare beneficiaries; (3) some groups representing disabled persons believe that the disabled need DMEPOS to accomodate a more active lifestyle than aged beneficiaries; and (4) the Health Care Financing Administration (HCFA) restricts coverage to standard DMEPOS items unless the beneficiary's physician prescribes and justifies lightweight materials or customized items on medical grounds, which is consistent with current Medicare law.

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