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Does Medicare Cover Back Braces ?

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Over the last year or so, my mom’s back has been becoming very tired and rather hunched over, and mom and I have been discussing what she can do about this. One of the options is back braces, so I started to take a tentative look at what’s out there. And then I wondered …

 

Does Medicare cover back braces ? Yes, Medicare Part B typically gives 80% coverage to “medically necessary” back braces prescribed by a Medicare-approved doctor, and bought, or rented, from a Medicare-approved supplier. 

Back braces are covered by Medicare Part B under the durable medical equipment prefabricated orthotics benefit.

 

Medicare qualifying guidelines for a back brace

 

To get coverage for a back brace, as I have already said, you will first need to obtain a signed prescription from a Medicare-enrolled doctor, stating that a back brace is “medically necessary”.

Medicare has guidelines about when coverage may be given to a patient for a back brace.

The following text is from Medicare’s guidelines for back braces, which they are calling “Spinal Orthosis” –

 

“A spinal orthosis (L0450 – L0651) is covered when it is ordered for one of the following indications:

1. To reduce pain by restricting mobility of the trunk; or

2. To facilitate healing following an injury to the spine or related soft tissues; or

3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or

4. To otherwise support weak spinal muscles and/or a deformed spine.

If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.”

 

In short, if you are to get coverage, the back brace has to be used to do one of the following  –

 

  • to reduce pain by restricting movement of the torso
  • promote with the healing of the spine or muscles, ligaments after an injury, or after surgery
  • give support to a weak spinal muscle and/or a deformed spine

Medicare-approved back braces ?

 

Medicare will only cover rigid or semi-rigid  braces of any type.

The two following exerts were taken from the Medicare Benefit Policy Manual, Chapter 15-

“A brace includes rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”

The text goes on to say

“Back braces include, but are not limited to, special corsets, e.g., sacroiliac, sacrolumbar, dorsolumbar corsets, and belts.”

There are many back braces to choose from, and of course your Medicare-enrolled doctor will advise you on that.

 

Some of the more popular brands are –

 

  • Aspen
  • Corflex
  • Comfortland
  • Ossur

 

You will though have to get your brace from a Medicare-enrolled supplier, and he will have the brands he works with, so you may have to check out a number of suppliers.

 

Decompression back braces covered by Medicare

Medicare Part B, under certain conditions, does cover some decompression back braces.

If you want to get one with Medicare coverage, you will need to have it prescribed for you by a Medicare-enrolled physician, and it has to be medically necessary.

Two examples of decompression back braces covered by Medicare are –

 

  • Dr Ho’s decompression back belt
  • DDS 500 Lumbar decompression brace

 

How often will Medicare pay for a back brace ?

 

Medicare Part B replaces covered DME  that are –

 

  • worn out through use
  • that have been in your possession for their entire lifetime
  • so worn out that they can’t be fixed
  • the minimum period considered to be a lifetime for DME is five years
  • the lifetime can vary depending on the type of equipment

 

Typically, a back brace which is worn out can be replaced every five years, as long as it has been in the beneficiary’s possession for that whole period.

Medicare will pay to repair worn out items which don’t reach the end of their lifetime, but no more than the cost of a replacement.

When an item is replaced after 5 years, or when worn out, the claimant will go through the whole Medicare procedure again, starting with their Medicare-enrolled doctor.

 

Does Medicare cover knee braces ?

 

Yes, Medicare Part B typically covers knee braces which have been prescribed as “medically necessary” by a Medicare-enrolled doctor, and acquired through a Medicare-approved supplier.

Medicare knee brace qualifying guidelines

 

To get a knee brace, you must first have an in-person appointment with a Medicare-enrolled doctor, so that they can make a diagnosis, to see if under the Medicare guidelines you qualify for a knee brace.

Medicare Part B gives covers knee braces as Durable Medical Equipment under the Orthotics Benefit.

 

Medicare considers a knee brace to be “medically necessary” when –

 

  • a person is able to walk
  • a knee requires stabilization because of weakness or deformity
  • you have had a recent injury to the knee
  • you recently had a knee surgery, such as a knee joint replacement

     

    To qualify, a Medicare-enrolled doctor will have to give you a prescription certifying that your knee brace is “medically necessary”.

    The doctor will prescribe a certain type of knee brace for your condition, which will have an equipment code, and this is the only type of brace you will be allowed to have.

    The following text from Medicare outlines the functions the braces must be able to perform, and that they may be either rigid, or semi-rigid.

     

    Medicare Benefits Policy Manual Chapter 15 – Revised 2019  here

    130 – Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes (Rev. 1, 10-01-03) B3-2133, A3-3110.5, HO-228.5, AB-01-06 dated 1/18/01

    These appliances are covered under Part B when furnished incident to physicians’ services or on a physician’s order.

    A brace includes rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Elastic stockings, garter belts, and similar devices do not come within the scope of the definition of a brace. 

    Adjustments, repairs and replacements are covered even when the item had been in use before the user enrolled in Part B of the program so long as the device continues to be medically required.

     

    Medicare-approved knee braces ?

     

    Medicare approves four types of knee braces

    Medicare coverage includes four types of knee orthotics.

    Devices must help manage stability or give pain relief and allow the patient to carry out daily functions.

    Functional  these braces are worn to give support to knees which have been injured in the past.

    Functional braces may be used after surgeries to give support to the knee.

     

    Rehabilitative or Postoperative – these braces, while allowing the joint to move, will protect ligaments and tendons after surgery by limiting potentially harmful movements during the rehabilitation.

     

    Unloader or Off-loader – often to reduce pain from osteoarthritis.

    Unloader braces take pressure off the sides of the knee by limiting the sideways movement, and by putting the pressure on the thigh.

     

    Prophylactic – made for the prevention of knee ligament injuries, in particular the MCL ligament, these are frequently used by athletes and footballers.

     

    Custom Fitted and Off-The-Shelf

    Medicare Part B allows both Custom Fitted and Off-the-Shelf knee braces.

     

    Custom Fitted braces

    Custom fitted braces can require a significant amount of alteration during the fitting to make them fit correctly, this has to be done by a certified Orthotist.

     

    Off-The-Shelf braces

    These may be supplied as a kit, requiring only a minimal adjustment for to be fitted properly.

    These should not require the help of a certified Orthotist for the best possible fit.

     

    Medicare 5 year replacement rule

     

    Medicare Part B replaces covered durable medical equipment that  –

    • has been worn out through use and has always been in your possession for its whole lifetime
    • an item’s lifetime may vary, but when it comes to getting a replacement, a lifetime is five years from the day you got it
    • if the item must be completely worn out that it cannot be repaired

     

    Medicare will cover the repair of worn out items which haven’t reached the end of their lifetime, but not more than the cost of a replacement item.

    When replacing an item, the claimant has to go through the whole procedure of having an appointment with a Medicare-enrolled doctor to get a new prescription for the replacement item.

     

    Medicare-approved braces and devices

    Medicare Part B covers quite a number of braces and supports.

    “A brace includes rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.

    Elastic stockings, garter belts, and similar devices do not come within the scope of the definition of a brace.”

     

    The following types of braces are all covered by Medicare Part B in certain circumstances, and when prescribed by a Medicare-enrolled physician.

    Back braces  –

    • Lumbar Sacral Braces
    • Thoracic Lumbar Sacral Braces

     

    Shoulder braces

    • shoulder immobilizers
    • shoulder cradles
    • shoulder stabilizers

     

    Neck braces

    • cervical collars
    • some cervical traction collars

     

    Foot and ankle braces –

    • ankle-foot (AFO)
    • knee-ankle-foot (KAFO)

     

    Knee braces –

    • rehabilitative
    • functional
    • unloader or off-loader
    • prophylactic

     

    Elbow braces –

    • elbow immobilizer

     

    Wrist braces –

    • braces
    • supports
    • splints

     

    What equipment does Medicare cover ?

     

    Medicare Part B covers durable medical equipment, or DME, for use in the home when they are “medically necessary”.

     

    Medicare typically covers items of durable medical equipment, such as –

     

    • wheelchairs
    • bedside commodes
    • walkers
    • crutches
    • back braces
    • hospital beds

     

    Conversely, Medicare does not cover disposable supplies in most cases, i.e. terms such as –

     

    • gloves
    • bandages
    • fabric dressing
    • disposable masks

     

    The Medicare Home Health Care Benefit does cover some disposable supplies.

     

    For equipment to qualify as durable medical equipment, it must –

     

    • be able to withstand constant use over a sustained period of time – durable
    • be for a medical reason only – not for comfort
    • useful to someone who is actually sick, and of little use to a person who is well
    • its primary use must be in the home
    • it has to be able to last at least 3 years

    How do you get coverage from Medicare Part B for DME ?

     

    To get coverage from Medicare Part B for durable medical equipment for “use in the home” –

     

    • you need to be enrolled in Medicare Part B
    • you need your Medicare-enrolled doctor to give you a signed prescription which states that the equipment is a “medically necessary” 
    • you need to purchase or to rent the equipment through a Medicare-enrolled supplier

     

    Medicare defines  “living at home” as –

     

    • living in your own home
    • living in the family home
    • living in the community, such as assisted living

     

    Now you have a signed prescription from your Medicare-enrolled doctor, what’s next ?

     

    Now that you have your prescription –

     

    • you will have to find a Medicare-enrolled DME supplier
    • only go through a supplier who is a Medicare-enrolled “participating supplier who accepts “assignment’ – this ensures you pay only what you have to
    • Medicare only gives coverage to pretty basic models of each equipment type, although you may sometimes be able to upgrade with certain DME by paying the difference yourself
    • select your DME that you have been prescribed from the available choices
    • sort out the necessary paperwork with the supplier – any forms etc

     

    Medicare part B covers 80% of the Medicare-approved price for DME if you used a Medicare-enrolled supplier with a signed prescription from a Medicare-enrolled doctor saying that your item is “medically necessary”.

    If you used a Medicare-enrolled “participating” supplier who accepts “assignment”, you will just have to pay your Medicare 20% co-payment of the Medicare-approved price for your DME, and your deductible if it applies.

    Do get your item through a Medicare-enrolled supplier who is a Medicare-enrolled “Participating” supplier who accepts “assignment”, if you don’t, you can end up paying way too much.

     

    Medicare will either rent or purchase DME – for the majority of equipment, and especially the pricier items, Medicare will rent from the supplier.

    If your equipment is rented, you will just pay a 20% co-payment of the monthly rental, and if it applies, your deductible, at the outset.
     

    Finding a local Medicare-enrolled DME Supplier near you

     

    You can use this link to find a Medicare-enrolled supplier who is local to you –  Medicare.gov

     

    What if you have a Medicare Advantage Plan ?

     

    Medicare Advantage plans cover at least everything offered by Medicare and sometimes, depending on the plan, a little more.

    In this case, as back braces are covered by Original Medicare, so they will also be covered by Medicare Advantage plans.

    To find out which suppliers and doctors to use, you will need to contact your plan provider.

    If you go outside your provider’s network, you will doubtless lose coverage.

    Durable Medical Equipment generally covered by Medicare if you qualify

     

    If you don’t find the equipment you are looking for in my list of  Medicare covered DME below, you can use this link to Medicare.gov 

    Air-Fluidized Bed
    Alternating Pressure Pads and Mattresses
    Audible/visible Signal Pacemaker Monitor
    Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
    Bead Bed
    Bed Side Rails
    Bed Trapeze – covered if your loved one is confined to their bed and needs one to change position
    Blood sugar monitors
    Blood sugar (glucose) test strips
    Canes (however, white canes for the blind aren’t covered)
    Commode chairs
    Continuous passive motion (CPM) machines
    Continuous Positive Pressure Airway Devices, Accessories and Therapy
    Crutches
    Cushion Lift Power Seat
    Defibrillators
    Diabetic Strips
    Digital Electronic Pacemaker
    Electric Hospital beds
    Gel Flotation Pads and Mattresses
    Glucose Control Solutions
    Heat Lamps
    Hospital beds
    Hydraulic Lift
    Infusion pumps and supplies (when necessary to administer certain drugs)
    IPPB Machines
    Iron Lung
    Lymphedema Pumps
    Manual wheelchairs and power mobility devices (power wheelchairs or scooters needed for use inside the home)
    Mattress
    Medical Oxygen
    Mobile Geriatric Chair
    Motorized Wheelchairs
    Muscle Stimulators
    Nebulizers and some nebulizer medications (if reasonable and necessary)
    Oxygen equipment and accessories
    Patient lifts (a medical device used to lift you from a bed or wheelchair)
    Oxygen Tents
    Patient Lifts
    Percussors
    Postural Drainage Boards
    Quad-Canes
    Respirators
    Rolling Chairs
    Safety Roller
    Seat Lift
    Self-Contained Pacemaker Monitor
    Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
    Sitz Bath
    Steam Packs
    Suction pumps
    Traction equipment
    Ultraviolet Cabinet
    Urinals (autoclavable hospital type)
    Vaporizers
    Ventilators
    Walkers
    Whirlpool Bath Equipment – if your loved one is home bound and the pool is medically needed. If your loved one isn’t home bound, Medicare will cover the cost of treatments in a hospital.

     

    Prosthetic and Orthotic Items

    Orthopedic shoes only when they’re a necessary part of a leg brace
    Arm, leg, back, and neck braces (orthotics), as long as you go to a supplier that’s enrolled in Medicare
    Artificial limbs and eyes
    Breast prostheses (including a surgical bra) after a mastectomy
    Ostomy bags and certain related supplies
    Urological supplies
    Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease. 

    Get free assistance with understanding Medicare

    SHIP – State Health Insurance Assistance Programs –

    Do you need help with understanding Medicare, Medicaid and Medigap?

    The SHIP in your state offers free counseling services over the phone for all three.

    To find the SHIP contact info in your state, you can go to my short guide on doing that right here“Free Help Understanding Medicare And Medicaid ? Here’s Where You Get It”.

    Does Medicaid cover back braces and other DME ?

     

    Medicaid has a very different structure from Medicare, as its programs are funded both federally and by each individual state.

    Concretely, this means that each individual state has quite a lot of leeway with what it does on its Medicaid programs, so long as it follows the Medicaid guidelines.

    It is not uncommon for Medicaid to allow a state to waive some of its eligibility requirements for a program, so that a state may be able to give health care to people who might otherwise not get it.

    When this is done, it’s known as a Waiver, and each different waiver can have specific eligibility requirements targeting specific elements of the population,  and often with limited places.

    This has resulted in hundreds of waivers, all with different eligibility, and all across the US.

     

    Care in the home – Medicaid and state programs

    Programs primarily for low income families, the disabled and the elderly, which work to help them maintain their independence in their homes and in the community are called “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”.

    As part of helping the elderly participants to maintain their independence, HCBS programs and waivers, and 1915 waivers will all help to cover “home medical equipment”, and very frequently, will cover it up to 100%.

    If you would like to find out if you are eligible for an HCBS program or waiver, contact your State Medicaid Agency here.

    You should also be able to find out more at your local Area Agencies on Aging.

    Use the link below to find out more on HCBS programs or waivers –

    https://www.medicaid.gov/medicaid/hcbs/authorities/index.html

     

    Medicaid uses the term “home” to mean any of the following –

     

    • their own home
    • their family home
    • a group home
    • an assisted living facility
    • a custodial care facility

     

    Programs and waivers which will likely cover more varied DME for “in home use”

     

    HCBS programs and waivers working with “Consumer Direction”or “Self Direction” 

    “Consumer Direction”or “Self Direction” is essentially a money management model, where the program participant is largely in charge of how their program budget is spent. Each participant is given a budget so that they may manage their needs and live independently – to do so, the participant will be given the help of an appointed a financial advisor.

    If the participant being needs certain equipment to be part of the program or waiver, as long as the budget covers it, they will, more often than not, be able to get it.

    Learn more about Medicaid Self Direction here.

    Money Follows the Person

    Money follows the person – this Medicaid program works with elderly adults who are in nursing care, and if they are able, helps to transition them back to living, somewhat independently, in their own homes.

    Items which are required both for making the transition, and then to the elderly person maintaining their independence, are paid for by the program.

    This can be buying standard DME, or it can be as much as remodeling parts of a home to make the move possible.

    The range of DME allowed is considerably wider than with Medicare, which certainly does not cover home modifications.

     

    How to find the HCBS programs, waivers and 1915 waivers in your state

     

    If you are trying to find out which Medicaid HCBS waivers and programs for seniors are running in your state, you can take a look at my guide which lists them all by state, as well as the Money Follows The Person Programs and PACE Programs (Programs of All-inclusive Care for the Elderly). You’ll find the guide here – “Medicaid Home and Community Based Services Waivers and Programs For Seniors Listed By State”.

     

    How to get DME with Medicaid and state waivers and HCBS programs ?

     

    Step 1

    – the doctor, or therapist, has to provide a medical justification letter, stating it is medically necessary

    Step 2

    –  find a Medicaid-approved DME supplier, and give them the medical justification letter

    Step 3

    – the Medicaid-approved supplier fills out a Prior Approval Application form for Medicaid

    Step 4

    – the Prior Approval Application is sent to the Medicaid State Office

    Step 5

    – if you are unsuccessful you will be contacted  and given the reasons as to why, as well as advice on how to make an appeal

    Step 6

    – if approved, you will receive the DME

     

    If your income is a bit too high to qualify for Medicaid

     

    Spend Down Programs

    Spend Down programs are a Medicaid initiative to lower participants’ income and, or asset levels, so that they may eventually qualify for Medicaid coverage.

    In what is called a “spend down” certain expenses may be deducted from a program participant’s income, so that their income level drops below the limit allowed for Medicaid, and the participant becomes qualifies for Medicaid coverage.

    I wrote a post about who can qualify for Spend Down, which expenses a person can deduct, and how you find out if you qualify for the program – “What is Spend Down ?”

     

     

    To find your State Medicaid State Agency

    Step 1 –

    Click the link to Medicaid.gov, look to the section I outlined in red.

     

     

    Step 2 –

    Select your state and click on the button they have marked “GO” – it will take you to your State Medicaid Agency with all their contact info.

     

    State Funding Assistance

     

    Assistive Technology Programs

     

    Assistive Technology Programs are present in each state to improve access to assistive devices in the home, with a primary focus on the elderly and the disabled.

    The classification “Assistive Technology” covers equipment which enables users to complete tasks they otherwise couldn’t – it can be anything from kitchen safety equipment through to digital devices.

     

    To find out what programs your state runs, click here

    Step 1/

    Pick your state on the map or the drop-down menu, and click on “Go to state”

    – I chose Florida for this example

     

    Step 2/

    Click on the link “Program Title” – for my example, I outlined it in red.

     

     

    Step 3/

    The AT Program state website will come up, and you can sign up, or use their contact info .

     

     

    State Financial Assistance Programs

    In a number of states, you can find non-Medicaid programs which help the elderly to remain living in their homes.

    The programs will pay for safety equipment, assistive equipment, and even the cost of remodeling bathrooms, kitchens, wheelchair ramps – the costs are paid for with grants or loans, or a combination of both.

    You can find out about these from your local Area Agency on Aging.

    To locate your local Area Agency on Aging, click here.

     

    Summary

     

    You can get rigid and semi-rigid back braces covered by Medicare Part B, if you have a signed prescription from a Medicare-enrolled doctor stating that it is “medically necessary”.

    You must get your brace through a Medicare-enrolled “Participating” supplier who accepts “assignment” and you will only have to pay a co-payment of 20%, and your deductible if it applies.

    I’m Gareth and I’m the owner of Looking After Mom and Dad.com

    I have been a caregiver for over 10 yrs and share all my tips here.

    Gareth Williams

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