Medicare will not pay for special features or upgrades for your durable medical equipment (DME) items unless your doctor can show that they are medically necessary and includes them in your DME order or prescription.
Medicare will generally only pay for the most basic form of the equipment that you need. For example, Medicare will pay for your medically necessary power wheelchair to get around the house, but if you want added features that are not medically necessary, such as a special kind of back rest or a tilt function for the seat, you will most likely have to pay for these added features yourself.
If your doctor is prescribing an upgraded piece of equipment, and the supplier does not think that Medicare will pay for it, the supplier must have you sign a waiver form called an Advance Beneficiary Notice (ABN). If you sign the ABN, you agree that you will be fully responsible for the cost of the upgrade or special features if Medicare denies coverage for them. (Even if Medicare will not pay for the upgrade, it may still pay the amount for a basic version of the equipment.)
A Medicare-enrolled supplier should be able to tell you whether or not Medicare will pay for an upgrade or special features for your equipment.
For more information on Advanced Beneficiary Notices, click on the link in the GO TO box.
If you sign an ABN and Medicare denies payment, you can appeal the denial if you believe the upgrade was medically necessary.
To find out more about your Medicare rights and protections if Medicare denies payment for items or services, click on the link in the GO TO box.