Does Medicare Cover Wrist Braces ?
This week I have been taking a good look at different types of wrist braces, as I am trying to find something that could help my Mom with an arthritic, and rather weak wrist. And as usual I am also looking at how much this will cost …
Does Medicare cover wrist braces ? Yes, Medicare Part B covers “medically necessary” wrist braces, as well as wrist supports and splints, if they have been prescribed by a Medicare-approved doctor. If you can’t get coverage under Medicare you may be able to under other state funded programs for the elderly.
Medicare Part B will typically cover 80% 0f the cost a wrist and forearm brace if it is “medically necessary”, under the Benefit for Orthotics or Braces, and to qualify your wrist must need –
- stabilization of the wrist or forearm because of a weakness or deformity
- restriction of the movement of the wrist or forearm due to an injury or disease
- limitation of movement of the wrist or forearm during recovery from a surgical procedure on them
You will have to see a Medicare-enrolled doctor for a face-to-face appointment, and get a signed prescription certifying that you qualify and the brace is “medically necessary”.
Medicare also covers splints and supports for wrist sprains and conditions such as carpel tunnel syndrome if your Medicare-enrolled doctor deems it “medically necessary” for you to have one.
What type of wrist brace are you allowed ?
Medicare Part B gives coverage to both Custom Fitted and Off-the-Shelf wrist and forearm braces.
The difference between the two types of braces –
Custom Fitted braces –
Even though they may come as a kit, the custom fitted braces require fitting by a certified Orthotist, as they can require a significant amount of alteration during the fitting to make them fit correctly.
Off-The-Shelf braces –
These may be supplied as a kit that demands some assembly, but should require only a minimal adjustment by the beneficiary to fit properly, and do not require the help of a certified Orthotist for the best possible fit.
The passage below is from the 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.”
Does Medicare cover back braces ?
Medicare Part B will cover back braces if they are “medically necessary” under the Benefit for Orthotics or Braces.
You will need to have a face-to-face appointment with a Medicare-enrolled doctor, and get a signed prescription certifying that a back brace is “medically necessary” in your case.
Medicare has guidelines about when coverage may be issued to a patient for a back brace which the doctor has to check before giving you the signed prescription.
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 do one of the following for you –
- 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 muscles and/or a deformed spine
If you do not qualify under one of these criteria the doctor can’t prescribe the brace for you.
What type of back brace are you allowed ?
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.”
Does Medicare cover knee braces ?
Typically, a knee brace which has been prescribed by a Medicare-enrolled doctor as “medically necessary” will be covered by Medicare Part B.
You will need to have a face-to-face appointment with a doctor so that they can make the diagnosis, and then consider if your condition qualifies under the Medicare guidelines.
If you would like to read more about this, I have an article about Medicare and knee brace coverage. I cover the different types of brace, the conditions which qualify for coverage for a brace. If you aren’t eligible I outline a number of different options including Medicaid and other state programs which can help if you qualify for those. You can read the article here.
Does Medicare cover “walking boot” ?
Medicare Part B will typically cover 80% of the cost of a”walking boot”, or ankle/foot orthosis, as Durable Medical Equipment (DME) under the benefit for Orthotics or Braces.
Medicare will cover the “walking boot”, or ankle/foot orthosis –
- if the “walking boot” is either rigid or semi rigid – not soft
- if the “walking boot” is being use to immobilize the foot/ankle after orthopedic surgery or for an orthopedic condition
Medicare does not give coverage if the boot is used to relieve pressure from foot ulcers, or other conditions, which may cause such sores on the feet.
Medicare covers foot ulcers under therapeutic shoes.
Will Medicare cover your bathroom safety equipment ?
Some types of equipment you won’t be able to get coverage from Medicare Part B for, even though they may seem to be very important for the prevention of accidents for the elderly.
This is because safety devices are not generally medical in nature, and so can’t be classed as “medically necessary”.
Other items which Medicare considers to be just “for comfort” or “for convenience” don’t qualify either.
So, unfortunately you are going to find that almost all of what could be considered safety equipment for the bathroom is not covered by Medicare.
Equipment for bathroom safety not covered by Medicare –
- grab bars
- raised toilet seats
- bath lifts
- bath seats
- floor to ceiling poles
- shower chairs
- bath chairs
- transfer seats
- toilet safety frames
Medicare does cover the following equipment if it is prescribed as “medically necessary” –
- bedside commodes
Luckily, if you can get coverage for these items they can be used in the bathroom to help with stability and mobility issues.
Medicare 5 year replacement rule
Medicare Part B replaces covered DME that are –
- worn out through use
- that have always been in your possession
- too worn out to 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 (knee braces last 1-2 years)
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.
How does Medicare decide on which equipment it will cover ?
Equipment that Medicare covers for use in the home is called “Durable Medical Equipment”, or DME.
For a piece of equipment to qualify as Durable Medical Equipment it must –
- be able to withstand constant use over time – durable
- primarily medical – not for comfort
- only of use to a sick person
- it must be primarily for use in the home
- it must last at least 3 years
How do you get coverage for a wrist, knee or back brace from Medicare Part B for DME ?
To be able to get covered by Original Medicare Part B for Durable Medical Equipment for “use in the home” –
- you must be enrolled in Medicare Part B
- you have to have a Medicare-enrolled doctor to give you a signed prescription which certifies that the DME is a “medically necessary”
- your equipment supplier must be a Medicare-enrolled supplier
For Medicares purposes “living at home” means –
- living in your own home
- living in the family home
- living in the community, such as assisted living
Once you have a signed prescription what’s next ?
Now you can get your DME –
- it’s time to visit a Medicare-enrolled DME supplier
- be sure the supplier is a Medicare-enrolled “participating” supplier who accepts “assignment’ – this guarantees you pay only 20% of the Medicare-approved price
- despite the fact that Medicare only covers the most basic of models, you can sometimes, if you pay extra, get upgrades
- select your DME that you have been prescribed from those on offer
- sort out the necessary paperwork in compliance with Medicare’s rules
So long as you used Medicare-enrolled supplier and the prescription is from a Medicare-enrolled doctor certifying that the DME is “medically necessary”, Medicare part B will typically cover 80% of the Medicare-approved price for DME.
If you have used a Medicare-enrolled “participating” supplier who accepts “assignment”, you will only have your Medicare 20% co-payment of the Medicare-approved price to pay for the DME, plus your annual deductible if it applies.
Always use a Medicare-enrolled supplier who is a Medicare-enrolled “Participating” supplier who accepts “assignment”, If you don’t you pay so much more than you need to.
Medicare will either rent or purchase your DME – when Medicare rents the DME, rather than buying it, the payment structure remains the same – you will still pay a 20% co-payment, but of the monthly rental fee, and you pay it each month.
Finding a local Medicare-enrolled DME Supplier near you
What if you have a Medicare Advantage Plan ?
Medicare Advantage plans cover, at a minimum, at least everything covered by Original Medicare and sometimes, depending on the plan some extras.
So, as wrist braces are covered by Original Medicare, so they are also covered by Medicare Advantage plans.
You will need to contact you plan provider, to get all the specifics about doctors and suppliers, as they will use their own network, and won’t provide coverage if you go outside of it.
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 Mediace.gov
Alternating Pressure Pads and Mattresses
Audible/visible Signal Pacemaker Monitor
Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
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)
Continuous passive motion (CPM) machines
Continuous Positive Pressure Airway Devices, Accessories and Therapy
Cushion Lift Power Seat
Digital Electronic Pacemaker
Electric Hospital beds
Gel Flotation Pads and Mattresses
Glucose Control Solutions
Infusion pumps and supplies (when necessary to administer certain drugs)
Manual wheelchairs and power mobility devices (power wheelchairs or scooters needed for use inside the home)
Mobile Geriatric Chair
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)
Postural Drainage Boards
Self-Contained Pacemaker Monitor
Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
Urinals (autoclavable hospital type)
Whirlpool Bath Equipment – if your loved one is homebound and the pool is medically needed. If your loved one isn’t homebound 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
Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease.
Free help understanding Medicare
State Health Insurance Assistance Programs – SHIP – give free counseling about Medicare.
SHIP counselors also will give their time, and advice, for free to help you with understanding Medicare Advantage, Medigap and Medicaid benefits.
SHIP generally offers a phone service, but some of the state programs occasionally offer face-to-face appointments also.
If you want to talk to your local Medicare SHIP click here
How to contact a SHIP counselor in your state, step by step
Step 2 –
Click on a button to find your state – both buttons lead to the same menu
Step 4 –
You’ll get a new window with the contact info and phone number for you to call in your state
Does Medicaid cover wrist braces and other DME ?
All state Medicaid programs have a funding structure which is both federally and state funded, which leaves each state with a lot of leeway with they do with Medicaid, as long as they stick to basic guidelines.
Medicaid will allow all the states to waive different requirements for qualification on some of their programs so they may in turn provide health care to specific groups of individuals who might otherwise slip through the net.
It’s known as a Waiver when the requirements are waived by Medicare.
Waivers may have very specific eligibility criteria, usually have limited places and as a result will often have waiting lists.
This system has resulted in hundreds of waivers, all with different and quite specific eligibility criteria across the US.
Do follow this section down to the end to see how to find out what your state.
Care in the home – Medicaid and state programs
The state programs providing health care in the home, primarily for low income families, the disabled and the elderly, are called “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”.
These HCBS programs, waivers and 1915 waivers, work to help the participants to maintain their independence in their homes, often giving “home medical equipment” 100% coverage.
You can find out if you are eligible for an HCBS program, or waiver, with your State Medicaid Agency here.
If you prefer you can talk with your local Area Agencies on Aging.
Use the link below to find out more on HCBS programs or waivers –
Medicaid understands the word “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 with the most flexible DME rules
HCBS programs and waivers using “Consumer Direction”or “Self Direction” systems of budget self-management
This is a type of program structure where the participant self-manages their allocated budget across their needs, albeit with the assistance of an appointed financial advisor.
The participants choose the medical and safety equipment which is necessary to them being able to maintain their independence, and if it is covered by their budget, they are allowed to purchase it.
There is greater scope for what can be considered DME on these programs than on Medicare.
Learn more about Medicaid Self Direction here.
Money Follows the Person
The program Money Follows The Person is a federal Medicaid program which was established to assist elderly adults living in nursing homes to move back to their own homes.
The Medicaid program helps the states with the necessary funding to set up their own Money Follows The Person programs.
The states will either use HCBS waivers which already exist to assist the elderly in making the transition back to their homes, or they will use the funding to design, and establish, new programs for those purposes.
These programs will give money for all sorts of equipment, and also for any remodeling which is required for the move.
If you don’t quite qualify for Medicaid
In some states you can get help from a program called “Spend-Down”.
If an individual has an income level which is a little too high to qualify for Medicaid, the “Spend-Down” program helps that individual to reduce it, so that they may become eligible for Medicaid, HCBS’s and waivers.
One way of doing this is to allow the participant to deduct their medical expenses from their income.
If subsequently they fall below the Medicaid income limit, the participant will be allowed to apply for the different HCBS’s and waivers available to them under Medicaid in their state.
There is much more comprehensive information on the US NEWS website here.
How to get DME with Medicaid and state waivers and HBSC programs ?
– the doctor, or therapist, has to provide a medical justification letter, stating it is medically necessary
– find a Medicaid-approved DME supplier , and give them the medical justification letter
– the Medicaid-approved supplier fills out a Prior Approval Application form for Medicaid
– the Prior Approval Application is sent to the Medicaid State Office
– 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
– if approved, you will receive the DME
Find the HCBS programs, waivers and 1915 waivers with their eligibility criteria in your state
Step 2 –
Click on you state
Step 3 –
- your state Medicaid Agency marked with a (1), or
- your state Home and Community Based Services, Waivers and 1915 Waivers marked with a (2)
You will then see a page like this example below, with the programs and waivers in your state, and their eligibility criteria.
To find your State Medicaid State Agency
Step 1 –
Click the link to Medicade.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, and are another example of a program whose primary focus is on the elderly and the disabled.
The goal of the programs is to improve access to assistive devices in the home,
The classification “Assistive Technology” is somewhat similar to “Durable Medical Equipment”, but as well as medical items it also covers equipment which facilitates users to accomplish activities they otherwise could not. This could be anything from dressing for the arthritic through to digital tablets and communication devices.
Pick your state on the map or the drop down menu, and click on “Go to state”
– I chose Florida for this example
Click on the link “Program Title” – for my example I outlined it in red.
The AT Program state website will come up, and you can sign up, or use their contact info .
State Financial Assistance Programs
You can find non-Medicaid programs in some states which which focus on helping the participants to remain living in their homes.
In order to achieve their goals, the programs will give the participants grants, or loans, or a combination of the two.
The money can be used to pay for safety equipment, assistive equipment, the remodeling bathrooms and kitchens, wheelchair ramps – the participants’ medical and safety requirements for living securely in their homes are covered to a great extent by the programs.
The main target groups for such programs are the elderly and the disabled.
The best place to find out if your state has one of these programs is your local Area Agency on Aging.
Wrist braces, rigid and semi-rigid, qualify as Durable Medical Equipment for Medicare.
With Medicare part B, under certain conditions, you can get coverage for rigid and semi-rigid wrist braces, so long as you have a signed prescription from a Medicare-enrolled doctor certifying that its’ “medically necessary”.
You should always acquire your brace from a Medicare-enrolled “Participating” supplier who accepts “assignment” so that you will only have the co-payment of 20% of the Medicare-approved price, and your deductible if it applies.
Medicare also covers back, elbow, ankle/foot and knee braces under certain conditions.
Medicare Advantage covers the same braces as it has to offer the same coverage as Medicare. It will also, depending on the plan provider, have its own extras, but you will have to check what those may be with your plan provider, if you have an Advantage plan.
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