Who oversees Medicare medical equipment benefits?

Part B of Medicare covers claims for doctors, outpatient care, and durable medical equipment (DME), which usually is defined as equipment with a useful life of at least three years.

Durable equipment claims for people with Original Medicare (Parts A and B, usually with a Part D plan) are overseen by Medicare administrative contractors (MACs) who handle claims in different regions of the country. These businesses are hired by Medicare to handle claims, with their approval and denial process based on Medicare coverage rules.

In my experience, DME suppliers are not the decision makers here, but are only following what they’re told by the MACs. The MACs, in turn, usually point to the Centers for Medicare & Medicaid Services (CMS) in Washington as the final decision maker.

For people with private Medicare Advantage plans, the plans oversee DME claims.

DME claim denials can be appealed. This can take as many as five levels of appeals. People whose denials involve expensive equipment often hire private attorneys to represent them in the appeals process.

I don’t know if you’ve been turned down for this coverage by the MAC where you live. I also don’t know if your physician(s) have prescribed this particular wheelchair as medically necessary. If you have committed doctors on your side, they can make a big difference in reversing Medicare coverage denials.

The nonprofit Medicare Rights Center and the Center for Medicare Advocacy might help with appeals but are not heavily staffed and tend to help in situations where they think they can help create a new precedent for coverage.