Medicare Info Request

Sherman Oaks Medical Supplies will guide you through the entire process of obtaining a Power Wheelchair or Mobility Scooter through Medicare. Based on Medicare guidelines, we are responsible for delivery, setup, and training of equipment, therefore

1. Form
2. Medicare
   • 1-2-3 Steps
   • What is Covered by Medicare?
   • How do I obtain Medicare coverage for medical equipment I need in home?
3. Medi-Cal
4. Blue Cross - Anthem
5. Blue Shield
6. TRICARE
7. L.A. Care
8. Gold Coast
9. Care1st

Medicare

1-2-3 Steps

	The Phone Call The process begins with your call or e-mail to request information about Power Wheelchairs or Mobility Scooters. Our Mobility Specialists will answer every question you have and gather the necessary information (address, phone number, medical problems, etc.) to create your confidential file.
	The Doctor's Visit The next step is meeting with your doctor for your mobility evaluation. Medicare requires a doctor's prescription for Power Wheelchairs coverage. (If you plan to use Medicare for payment, it is important to schedule your doctor's appointment right away.) This doctor's visit must be specifically for your face-to-face mobility evaluation, not a general appointment. During the mobility evaluation, your doctor will ask you a series of questions to determine if a power mobility product is medically necessary. If your doctor prescribes a power mobility device, we work with your doctor to complete the Medicare paperwork. Print Medicare Coverage Criteria and take to your doctor.
	The Paperwork We work with Medicare to complete the paperwork process. We have over 10 years experience working with Medicare and can help you get the right equipment for you at little or no cost to you.

View Medicare Eligibility Guidelines here.

The Right Chair
We fit your Power Wheelchair to your body measurements for complete comfort. We guarantee your new Power Wheelchair will fit your body proportions and will work in your home.

Delivery and Training
We deliver our Power Wheelchairs and Mobility Scooters right to your home with no delivery fees. At delivery, we teach you how to operate your new Power Wheelchair throughout your home. Based on Medicare guidelines, we are responsible for delivery, setup, and training of equipment, therefore we cannot provide service for Medicare beneficiaries that live outside of our area.

Service
We have in home as well as in store service for your convenience. Most service issues can even be solved over the phone or in your home. If your Power Wheelchair requires more extensive repairs, a temporary loaner can be provided until your Power Wheelchair is repaired.

What is Covered by Medicare?

Medicare Part B helps pay for durable medical equipment, including;

• Manual Wheelchairs (capped rental item)
• Power Wheelchairs (reimbursable item)
• some positioning devices
• Walkers, Canes, Crutches
• Mobility Scooters
• Seat-Lift Mechanisms for Lift Chairs, Manual Patient Lifts 
• Mattress Overlays
• Hospital Beds, Semi-Electric only (capped rental item)
• Oxygen Equipment
• Orthotics (Splints)

Durable medical equipment such as Manual Wheelchairs are covered only when meeting the correct criteria, prescribed by a doctor and when provided by a supplier approved by Medicare. You can find out what equipment is covered, and whether a supplier is approved, by calling Medicare's durable medical equipment (DMERC) regional carrier for your area.

How do I obtain Medicare coverage for medical equipment I need in home?

Your physician must write a prescription. The physician must then complete and sign a Certificate of Medical Necessity (CMN), or a form that describes the nature of your condition, this is called a Written Confirmation of Verbal Order (WCVO). We forward the Certificate of Medical Necessity (CMN) or Written Confirmation of Verbal Order (WCVO) to the physician. The physician completes these forms and returns them to us for submission.

Medi-Cal

Medi-Cal covers Durable Medical Equipment (DME) when provided on the written prescription of a licensed practitioner within the scope of his/her practice.

The Medi-Cal definition of medical necessity limits health care services to those necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. Therefore, prescribed DME items may be covered as medically necessary only to preserve bodily functions essential to activities of daily living or to prevent significant physical disability.

Alterations or improvements to real property (for example, a non-portable wheelchair ramp to front door) are not covered, except when authorized for home dialysis services. Claims for covered benefit portable ramps must be billed with HCPCS code E1399 (durable medical equipment, miscellaneous).

Blue Cross - Anthem

Rental of DME and purchase of custom equipment will require PA request.

Providers are required to get prior authorization of the following:

• Adjustable Cranial Orthosis for Synostotic and Non-Synostotic Indications
• Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering
• Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
• Automated External Defibrillators for Home Use
• Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump during the Post-Operative Period
• Continuous Passive Motion Devices
• Electrical Bone Growth Stimulation
• Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
• External (Portable) Continuous Insulin Infusion Pump
• Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
• Glucose Monitoring and Related Supplies
• Implantable Cardioverter-Defibrillator (ICD)
• Implantable Infusion Pumps
• Implantable Middle Ear Hearing Aids
• Implanted Devices for Spinal Stenosis
• Implanted Spinal Cord Stimulators (SCS)
• Microprocessor Controlled Lower Limb Prosthesis
• Myoelectric Upper Extremity Prosthetic Devices
• Oscillatory Devices for Airway Clearance including High Frequency Chest Compression (Vest™ Airway Clearance System) and Intrapulmonary Percussive Ventilation (IPV)
• Patient-Operated Spinal Unloading Devices
• Standing Frames
• Stretching Devices for the Treatment of Joint Stiffness and Contracture
• TempTouch® Dermal Thermometer
• Transtympanic Micropressure for the Treatment of Meniere's Disease
• Ultrasound Bone Growth Stimulation
• Vacuum Assisted Wound Therapy in the Outpatient Setting
• Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
• Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)

For DME not listed above or any other questions regarding DME, please contact the Anthem Blue Cross Utilization Management department at the following: For Medi-Cal Managed Care: 1-888-831-2246; for Healthy Families Program, AIM, and MRMIP: 1-877-273-4193.

Blue Shield

Purchase or rental up to the purchase price, including repair and adjustment, of durable medical equipment prescribed by your Plan physician. Replacement of DME is covered only when it no longer meets the clinical needs of the patient or has exceeded the expected lifetime of the item. Under this benefit, we cover:

• Oxygen
• Dialysis equipment
• Colostomy/ostomy supplies
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Canes
• Traction equipment
• Blood glucose monitors
• Apnea monitor for management of newborns
• Nebulizers, including face masks and tubing, and peak flow monitors for the management and treatment of asthma. See section 5(f) Prescription Drug Benefits for asthma inhalers and inhaler spacers.

Not covered:

• Exercise equipment
• Disposable medical supplies for home use, except colostomy/ostomy supplies
• Speech/language assistance devices except as listed under prosthetic devices
• Self-monitoring equipment and home testing devices, except as listed in the covered section
• Wigs
• Generators
• Backup or alternate items

TRICARE

TRICARE covers medical supplies and dressings (consumables) when related directly to a covered medical condition and obtained from a medical supply company, a pharmacy, or authorized institutional provider. Examples of covered medical supplies and dressings include disposable syringes for diabetics, colostomy sets, irrigation sets, elastic bandages and external surgical garments designed for use following a mastectomy.

Generally, the allowable charge of a medical supply item will be under $100. Any item over this amount must be reviewed to determine whether it would not qualify as a DME item. If it is, in fact, a medical supply item and does not represent an excessive charge, it can be considered for benefits under this policy.

L.A. Care

Durable Medical Equipment (DME) Coverage

These items are ordered by your doctor.

• Apnea monitors
• Blood glucose monitors, including monitors for the visually impaired, for insulin dependent, non-insulin dependent and gestational diabetes
• Insulin pumps and all related supplies
• Nebulizer machines
• Orthotics (shoe inserts)
• Ostomy bags
• Oxygen and oxygen equipment
• Prosthesis
• Pulmo-Aides and related supplies
• Spacer devices for metered dose inhalers
• Tubing and related supplies
• Urinary catheters and related supplies

Gold Coast

Gold Coast Health Plan is an independent public entity created by County Ordinance and authorized through Federal Legislation. GCHP is NOT a County Agency. The purpose of GCHP is to:

• Serve Medi-Cal Beneficiaries
• Enhance Quality of Healthcare
• Provide Access and Improve Service
• Provide Choice

Care1st

Care1st plan covers all of the medically-necessary services that are covered by Medicare Part A and Part B. The following items and services aren't covered under the Original Medicare Plan or by our plan:

• Services that aren't reasonable and necessary, according to the standards of the Original Medicare Plan, unless these services are otherwise listed by our Plan as a covered service
• Experimental or investigational medical and surgical procedures, equipment and medications, unless covered by the Original Medicare Plan or unless, for certain services, the procedures are covered under an approved clinical trial
• Surgical treatment of morbid obesity unless medically necessary and covered under the Original Medicare plan
• Private room in a hospital, unless medically necessary
• Private duty nurses
• Personal convenience items, such as a telephone or television in your room at a hospital or skilled nursing facility
• Nursing care on a full-time basis in your home
• Custodial care unless it is provided in conjunction with covered skilled nursing care and/or skilled rehabilitation services. This includes care that helps people with activities of daily living like walking, getting in and out of bed, bathing, dressing, eating and using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered
• Homemaker services
• Charges imposed by immediate relatives or members of your household
• Meals delivered to your home
• Elective or voluntary enhancement procedures, services, supplies and medications including but not limited to: Weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance unless medically necessary
• Cosmetic surgery or procedures, unless needed because of accidental injury or to improve the function of a malformed part of the body. All stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance
• Chiropractic care is generally not covered under the Plan, (with the exception of manual manipulation of the spine,) and is limited according to Medicare guidelines
• Orthopedic shoes unless they are part of a leg brace and are included in the cost of the brace. Exception: Therapeutic shoes are covered for people with diabetic foot disease
• Supportive devices for the feet. Exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease
• Radial keratotomy, LASIK surgery, vision therapy and other low vision aids and services
• Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy
• Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies and devices
• Acupuncture
• Naturopath services
• Non-emergency services provided to veterans in Veterans Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost-sharing is more than the cost-sharing required under our Plan, we will reimburse veterans for the difference. Members are still responsible for our Plan cost-sharing amount
• Any of the services listed above that aren't covered will remain not covered even if received at an emergency facility. For example, non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency are not covered if received at an emergency facility