Coverage checker
Will insurance cover it?
Pick the item and your insurance. See, in plain English, what's usually covered and what your doctor needs to do, plus the exact checklist for doctors' offices.
Runs on your device. Nothing you pick is sent anywhere. Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Your result
As of October 31, 2026
Usually covered when the criteria are met
Usually covered when…
- Your doctor writes down a walking or balance problem that makes everyday tasks at home, like getting to the bathroom or kitchen, impossible, unsafe or very slow.
- You can use a walker safely.
- A walker is enough to solve the problem.
- For a heavy-duty walker: you weigh more than 300 pounds.
What your doctor needs to do
- See you and note exactly how the problem affects daily tasks at home. "Difficulty walking" on its own isn't enough.
- Note that you can use a walker safely and that it will help.
- Sign a written order for the walker.
What to bring or ask for
- Your Medicare card, and any secondary insurance card.
- The name of the doctor treating you for this.
- Ask your doctor to write down what you can't do safely at home without a walker.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Mobility limitation that significantly impairs one or more mobility-related activities of daily living (MRADLs) in the home: prevents the task, puts the patient at heightened risk, or prevents finishing it in a reasonable time.
- The patient can safely use the walker.
- The functional mobility deficit can be sufficiently resolved with a walker.
- Heavy-duty walker (E0148, E0149): criteria above met and the patient weighs more than 300 lb.
- Multiple braking system (E0147): unable to use a standard walker because of a severe neurologic condition or another condition restricting use of one hand.
Required documents
- Standard written order: patient name or MBI, order date, item description, quantity (if applicable), practitioner name or NPI, practitioner signature.
- Medical record notes describing functional abilities and limitations in the home on a typical day, with objective findings from the exam of the body systems causing the difficulty.
- Weight, when a heavy-duty walker is ordered.
Common denial reasons
- Vague notes such as "difficulty walking" or "unsteady" without how it affects tasks at home.
- No statement that the patient can use the walker safely.
- Order missing an element, most often the signature or NPI.
- Accessories billed when the walker itself is not covered (they are denied too).
Source: LCD L33791 Walkers · Policy article A52503. As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Your doctor prescribes it as medically necessary.
- A wheeled walker is usually covered only when it's prescribed instead of a wheelchair, and it must have a seat and wheel locks.
- Standard walkers, canes and crutches come with their tips, pads and grips.
- Usually one walker every 3 years.
What your doctor needs to do
- Write a prescription (or certificate of medical necessity) with your diagnosis and why you need the walker.
- For a wheeled walker: say it is prescribed in place of a wheelchair.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Medically necessary (rule 59G-1.010).
- Wheeled walker: usually covered only when prescribed in lieu of a wheelchair (59G-4.075 4.2.1); must include a seat and wheel locks to be reimbursable.
- Canes, crutches and walkers must include tips, pads and grips.
- Fee schedule limit: 1 walker per 3 years (E0130–E0149).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Wheeled walker without a seat and wheel locks.
- Wheeled walker not documented as in lieu of a wheelchair.
- Prescription dated more than 21 days after delivery, or older than 12 months.
- A walker already supplied within the 3-year limit.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Your doctor writes down that moving around your home is hard enough to stop or slow everyday tasks, even with a cane or walker.
- Your home has room to use the wheelchair: doorways, hallways and floors.
- You can push the chair yourself safely, or someone is available and willing to push it for you.
- You'll use it regularly at home.
- From October 28, 2026, most wheelchairs other than the basic standard chair (for example lightweight, heavy-duty or tilt-in-space chairs) need a face-to-face visit with your doctor before the order, and a signed order before delivery. An ultralightweight chair also needs Medicare's approval before delivery.
What your doctor needs to do
- See you and note how the problem affects daily tasks at home and why a cane or walker isn't enough.
- Note whether you can push the chair yourself or have a caregiver who can.
- Sign a written order.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your height and weight.
- A rough idea of your doorway and hallway widths at home.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- A: Mobility limitation significantly impairs one or more MRADLs in the home.
- B: Not sufficiently resolved by an appropriately fitted cane or walker.
- C: The home provides adequate access between rooms, maneuvering space and surfaces for the wheelchair.
- D: Use will significantly improve MRADLs, and the patient will use it regularly in the home.
- E: The patient has not expressed unwillingness to use it in the home.
- Plus F (enough upper-extremity function and other capabilities to self-propel safely) or G (a caregiver available, willing and able to assist).
- Lightweight (K0003): cannot self-propel a standard chair in the home but can and does self-propel a lightweight one.
- Heavy duty (K0006): over 250 lb or severe spasticity. Extra heavy duty (K0007): over 300 lb.
- From 10/28/2026: K0002–K0007 and E1161 are on the required face-to-face (within 6 months before the order) and written-order-prior-to-delivery list (standard K0001 is not); K0005 (ultralightweight) is also on the Required Prior Authorization List from 10/28/2026 (Federal Register 2026-15446).
Required documents
- Standard written order (same six elements as every DME order).
- Notes painting a picture of functional abilities and limitations in the home on a typical day, with objective data.
- For upgrades (lightweight, high-strength lightweight, heavy duty): the specific criterion met, such as weight, self-propulsion ability or hours per day in the chair.
- Lightweight and heavier chairs (K0002–K0007) from 10/28/2026: face-to-face encounter note within 6 months before the order, and the signed order before delivery.
- K0005 from 10/28/2026: prior authorization affirmed before delivery.
Common denial reasons
- No explanation of why a cane or walker is not enough.
- No statement about self-propelling or caregiver help.
- Lightweight chair without documenting that the patient can't propel a standard chair but can propel the lightweight one.
- Vague notes such as "difficulty walking".
- From 10/28/2026: K0002–K0007 or E1161 delivered without a face-to-face note or a signed order before delivery; K0005 delivered before prior authorization was affirmed.
Source: LCD L33788 Manual Wheelchair Bases · Policy article A52497 · Federal Register 2026-15446: Master List, F2F/WOPD and Required Prior Authorization List updates, effective Oct 28, 2026 · CMS: Prior authorization process for certain DMEPOS items (update of 07/29/2026) · Face-to-face / written order before delivery list, effective Oct 28, 2026 (Noridian). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You can't walk, or your mobility is severely limited.
- Your doctor prescribes the wheelchair as medically necessary.
- Usually one wheelchair per person in each replacement period (the 2026 fee schedule lists standard chairs at 1 per 5 years).
- Custom chairs built for you need a therapist or physiatrist evaluation and prior approval.
What your doctor needs to do
- Write a prescription or certificate of medical necessity with your diagnosis.
- For a custom chair: refer you to a licensed therapist or physiatrist for the custom wheelchair evaluation.
What to bring or ask for
- Your Florida Medicaid ID card.
- Your height and weight, and any recent therapy evaluation.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Recipient is nonambulatory or has severely limited mobility.
- One wheelchair per recipient, per maximum unit period (fee schedule: K0001 1 per 5 years).
- Customized chairs: Custom Wheelchair Evaluation (AHCA Med Serv Form 015) completed by the licensed therapist or certified physiatrist; prior authorization.
- Wheelchair evaluations are valid for up to six months from the date the evaluator signs them.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Evaluation older than six months when the request is made.
- Custom chair requested without Form 015 or prior authorization.
- Another wheelchair already supplied within the replacement period.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- Your doctor examines you in person and writes down that moving around your home is hard enough to stop or slow everyday tasks.
- A cane, walker or manual wheelchair can't solve the problem, for example because your arms aren't strong enough to push a chair.
- A scooter won't work either, for example because you can't sit steadily or steer one safely, or your home has no room for one.
- You can operate a power chair safely (or, if you can't, a caregiver can), your home has room to use it, and you're willing to use it at home.
- Medicare approves it in advance: most power chairs need prior authorization.
What your doctor needs to do
- See you in person for a mobility exam, focused on why you can't get around your home safely.
- Write the order after that visit, within 6 months, and before the chair is delivered.
- For many power chairs: a physical or occupational therapist does a separate mobility evaluation, and your doctor signs and agrees with it.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- A list of what you can't do at home now (bathroom, kitchen, getting to the door).
- Your height and weight. We also check your home before delivery.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Mobility limitation significantly impairs MRADLs in the home.
- Not sufficiently and safely resolved by an appropriately fitted cane or walker.
- Insufficient upper-extremity function to self-propel an optimally configured manual wheelchair in the home (strength, endurance, range of motion, coordination, pain, deformity or absence of limbs).
- The beneficiary does not meet coverage criteria for a POV (scooter): insufficient strength, postural stability or other ability to operate a POV safely in the home, or the home cannot accommodate a POV.
- The beneficiary has the mental and physical capabilities to safely operate the power wheelchair provided (or a caregiver who is unable to adequately propel an optimally configured manual wheelchair is available, willing and able to operate it safely); the home provides adequate access between rooms, maneuvering space and surfaces; use will significantly improve participation in MRADLs; the beneficiary has not expressed an unwillingness to use it in the home.
- Prior authorization required for PWC codes K0813–K0816, K0820–K0829, K0835–K0843 and K0848–K0864.
Required documents
- Face-to-face encounter with the treating practitioner: a complete physical exam focused on the body systems causing the mobility problem, describing abilities and limitations in the home on a typical day.
- Written order prior to delivery (WOPD) by the same practitioner, dated within 6 months after the face-to-face encounter.
- Specialty mobility evaluation by a licensed/certified medical professional (PT or OT) where the base requires it, co-signed and dated by the practitioner with a statement of agreement.
- Direct, in-person involvement of a RESNA-certified ATP in chair selection, for bases that require it (supplier side).
- Supplier home assessment (supplier side).
Common denial reasons
- Order written before the face-to-face exam, or more than 6 months after it.
- Notes don't explain why a cane, walker and manual wheelchair are each insufficient.
- Notes don't explain why a scooter (POV) won't work.
- PT/OT evaluation not signed and agreed to by the treating practitioner.
- Delivered before prior authorization was affirmed.
Source: LCD L33789 Power Mobility Devices · Policy article A52498. As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- You can't walk, or your mobility is severely limited.
- Your records show you can't operate a manual wheelchair, and that you can control a power chair on your own.
- Florida Medicaid approves it in advance (prior authorization).
- Custom chairs also need a therapist or physiatrist evaluation.
What your doctor needs to do
- Write a prescription or certificate of medical necessity with your diagnosis.
- Refer you for a wheelchair evaluation by a licensed therapist or physiatrist.
What to bring or ask for
- Your Florida Medicaid ID card.
- Any recent therapy evaluation, and your height and weight.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Recipient is nonambulatory or has severely limited mobility.
- Documentation of the recipient's inability to operate a manual wheelchair.
- Documentation of the recipient's ability to independently control the wheelchair.
- Prior authorization from the QIO when the fee schedule says PA (power wheelchairs, e.g. K0823) and for all custom chairs.
- Customized chairs: Form 015 evaluation by a licensed therapist or certified physiatrist; valid six months from signature.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- No documentation that a manual wheelchair can't be used.
- No documentation the recipient can control the chair independently.
- Evaluation older than six months.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Your doctor writes down a medical reason a regular bed won't work, for example you need your head raised more than 30 degrees most of the time for a heart or lung condition, special positioning to relieve pain, or traction.
- For a bed with electric head and foot (semi-electric): you also need frequent or immediate changes in position.
- Fully electric beds (with electric height) are not covered; height is treated as a convenience.
What your doctor needs to do
- Note the specific reason a regular bed won't work.
- For a semi-electric bed: note why you need frequent or immediate position changes.
- Sign a written order.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your weight (beds have weight limits).
- Room measurements where the bed will go, if you have them.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Fixed-height bed, any one of: positioning not feasible in an ordinary bed; positioning to alleviate pain; head of bed elevated more than 30° most of the time (CHF, chronic pulmonary disease, aspiration); traction that can only attach to a hospital bed.
- Variable-height: a fixed-height criterion plus a bed height different from fixed-height needed to transfer to a chair, wheelchair or standing.
- Semi-electric: a fixed-height criterion plus frequent or immediate changes in body position.
- Heavy duty extra wide (E0301, E0303): over 350 lb and up to 600 lb. Extra heavy duty (E0302, E0304): over 600 lb.
- Total electric beds are not covered (height adjustment is a convenience feature).
- Trapeze: needed to sit up for a respiratory condition, change position, or get in or out of bed.
Required documents
- Standard written order.
- Notes stating which fixed-height criterion is met.
- For variable-height or semi-electric: the additional need, described specifically.
- Weight, for heavy-duty beds.
Common denial reasons
- Notes support a fixed-height bed but not the variable-height or semi-electric feature billed.
- No specific reason a regular bed won't work.
- Insufficient documentation (the leading cause of improper payments for beds).
Source: LCD L33820 Hospital Beds and Accessories · Policy article A52508. As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- Your doctor prescribes it as medically necessary.
- Standard and adjustable-height beds usually need prior approval.
- A semi-electric or electric bed needs a record that you require frequent position changes and can work the controls yourself. The 2026 fee schedule lists these beds for members under 21.
- Heavy-duty beds: you weigh more than 350 pounds.
What your doctor needs to do
- Write a prescription or certificate of medical necessity with your diagnosis.
- Note the reason for the bed type, such as frequent position changes or weight.
What to bring or ask for
- Your Florida Medicaid ID card.
- Your weight.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Medically necessary (rule 59G-1.010).
- Semi-electric or electric: requires frequent changes in body position and can operate the bed controls independently.
- Heavy-duty: weighs more than 350 lb.
- Fee schedule: fixed-height (E0250) and variable-height (E0255) require PA; semi-electric (E0260) and total electric (E0265) listed for ages 0–20; 1 bed per 8 years.
- Trapeze: confined recipient needs help getting in or out of bed, changing position, or sitting up for a respiratory condition.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Semi-electric bed without documentation of frequent position changes and independent use of the controls.
- Bed ordered without prior authorization where the fee schedule requires it.
- Heavy-duty bed without a documented weight over 350 lb.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You can't move at all on your own, or
- You have limited mobility, or a pressure sore on your back, hips or buttocks, plus at least one of: poor nutrition, bladder or bowel incontinence, reduced feeling in your skin, or poor circulation.
- Your doctor or home care nurse has a care plan to prevent or treat pressure sores.
- A powered or air mattress (Medicare calls it Group 2) is for serious pressure sores on your back, hips or buttocks: several shallow (stage 2) sores that haven't improved in a month on a regular pressure mattress with a full treatment plan; large or several deep (stage 3 or 4) sores; or surgery (a flap or skin graft) for a pressure sore in the last 60 days, when you were on a powered mattress just before leaving the hospital or nursing facility in the last 30 days.
- A powered mattress needs Medicare's approval before delivery. Medicare keeps covering it while the sore heals; after flap or graft surgery, usually for 60 days.
What your doctor needs to do
- Note which of these applies to you.
- Set up a care plan: turning and positioning, skin checks, wound care if needed, nutrition and moisture management.
- For a powered mattress: record each sore's stage, size and location, and how it has changed over the past month (or the date of flap or graft surgery).
- Sign a written order.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- The name of your home health agency or nurse, if you have one.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Group 1 support surface, at least one of: (1) completely immobile; (2) limited mobility plus impaired nutritional status, fecal or urinary incontinence, altered sensory perception, or compromised circulatory status; (3) any stage pressure ulcer on the trunk or pelvis plus one of those same conditions.
- A care plan established by the treating practitioner or home care nurse: education, regular assessment, turning and positioning, wound care for stage 2–4 ulcers, moisture/incontinence management, nutrition.
- Group 2 support surface (L33642, rev. eff. 05/01/2021), at least one of: (1) multiple stage 2 pressure ulcers on the trunk or pelvis that have failed to improve over the past month while on a comprehensive ulcer treatment program; (2) large or multiple stage 3 or 4 pressure ulcer(s) on the trunk or pelvis; (3) a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days, and on a Group 2 or 3 support surface immediately before discharge from a hospital or nursing facility within the past 30 days.
- Comprehensive ulcer treatment program (Group 2 criterion 1): use of an appropriate Group 1 support surface; regular assessment by a nurse, practitioner or other licensed healthcare practitioner; appropriate turning and positioning; appropriate wound care; appropriate management of moisture/incontinence; nutritional assessment and intervention consistent with the overall plan of care.
- Group 2 continued coverage: until the ulcer is healed; if healing does not continue, the record must show other aspects of the care plan are being modified to promote healing, or that the Group 2 surface is reasonable and necessary for wound management. After a flap or graft, coverage generally runs 60 days from the date of surgery.
- Group 2 (E0193, E0277, E0371–E0373) requires prior authorization nationwide (CGS prior authorization page).
Required documents
- Standard written order.
- Notes documenting the mobility status and qualifying condition(s).
- The care plan, in the medical record.
- Group 2: ulcer stage, size and location with dates; for criterion 1, the past month on the comprehensive program and Group 1 surface; for criterion 3, the surgery date and the surface used before discharge; prior authorization affirmed before delivery.
Common denial reasons
- Order alone, without notes establishing the criteria (orders are not enough).
- No care plan documented.
- Records that don't match the standard written order.
- Group 2 for stage 2 ulcers without a documented month on a comprehensive program (Group 1 surface, assessment, turning, wound care, moisture and nutrition).
- Group 2 delivered before prior authorization was affirmed.
Source: LCD L33830 Group 1 Support Surfaces · LCD L33642 Pressure Reducing Support Surfaces - Group 2 · CGS: Pressure reducing support surfaces prior authorization (Group 2 codes). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Limited coverage: we check the exact item
Usually covered when…
- Florida Medicaid usually covers decubitus care equipment such as alternating pressure pads, mattresses and pressure ulcer care pads when medically necessary.
- On the 2026 fee schedule some items are listed for all ages and others only for members under 21. We check the exact item for you.
What your doctor needs to do
- Write a prescription or certificate of medical necessity with the diagnosis, such as a pressure ulcer or high risk.
- Include notes describing the skin condition and mobility.
What to bring or ask for
- Your Florida Medicaid ID card.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Decubitus care equipment (alternating pressure pads, bed pumps, mattresses, pressure ulcer care pads, wheelchair cushions) is a category listed under 59G-4.076; usually covered when medically necessary.
- Fee schedule examples: E0185 gel pad all ages (1 per 2 years); E0181 and E0184 listed for ages 0–20.
- The QIO may also apply review criteria approved by AHCA (Authorization Requirements Policy s. 3.1).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Item not on the fee schedule for the member's age.
- Prescription outside the 12-month / 21-day window.
Source: Florida Medicaid rule 59G-4.076 (Continence, Ostomy and Wound Care, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- A test of your oxygen level shows it's low enough: usually at or below 88% (or a blood gas at or below 55), at rest, while walking, or while asleep.
- The test is done by your doctor's office, a hospital or a lab, not by the equipment company.
- If oxygen is started when you leave the hospital, the test is usually done within 2 days before discharge.
- If you only qualify during sleep, Medicare usually covers oxygen for use during sleep only, not a portable unit.
What your doctor needs to do
- Evaluate you and note the condition oxygen is expected to improve.
- Order or perform the oxygen test, and note whether it was at rest, during exercise or during sleep.
- Sign a written order, including how much oxygen and when you use it.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Ask for a copy of your oxygen test result with its date.
- If you're in the hospital: ask the case manager to send the test and order before you go home.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Group I: arterial PO2 ≤ 55 mm Hg or SpO2 ≤ 88% at rest on room air; or during exercise (with documented improvement on oxygen); or during sleep (≤ 55 / ≤ 88%, or a drop of more than 10 mm Hg / 5% with associated symptoms).
- Group II: PO2 56–59 mm Hg or SpO2 89%, plus dependent edema suggesting CHF, pulmonary hypertension or cor pulmonale, or hematocrit over 56%.
- Test at the time of need; for inpatients, within the 2 days before discharge.
- Test performed by a qualified provider or lab, or ordered and supervised by the treating practitioner. A DME supplier is not a qualified tester.
- Sleep-only qualification: portable oxygen is denied.
- Group II: re-evaluation with a repeat qualifying test between days 61 and 90, and a new order.
Required documents
- Standard written order, plus the oxygen flow rate, frequency and duration of use.
- Notes on the treating practitioner's evaluation and the condition oxygen is expected to improve.
- The qualifying test result: date, value, and whether at rest, exercise or sleep (exercise: room air, exercising, and on oxygen).
Common denial reasons
- Test performed by the DME supplier.
- Test conditions (rest, exercise, sleep) not recorded.
- Exercise test missing the on-oxygen improvement.
- Portable oxygen billed when the patient qualified only during sleep.
- Insufficient documentation (most improper oxygen payments).
Source: LCD L33797 Oxygen and Oxygen Equipment · Policy article A52514. As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers home and portable oxygen when it's medically necessary.
- Your doctor includes test results showing your blood oxygen level.
- The prescription is filled within 30 days, or a new exam and prescription are needed.
- Your doctor renews it once every 12 months.
What your doctor needs to do
- Order a test of your blood oxygen level and include the result.
- Include test results showing the blood oxygen level (59G-4.074 s. 6.2.1). The prescription must be filled within 30 days and renewed every 12 months.
- Renew it every 12 months.
What to bring or ask for
- Your Florida Medicaid ID card.
- A copy of your oxygen test result.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Stationary and portable oxygen usually covered when medically necessary (59G-4.074).
- Test results specifying blood oxygen levels.
- Medical-necessity renewal from the treating practitioner every 12 months.
- Prescription filled within 30 days, otherwise a new examination and prescription are required.
- Setup and delivery supervised by a licensed professional (RN, CRT, RRT or RCP), supplier side.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- No oxygen test result in the file.
- Prescription older than 30 days when filled, or renewal missed at 12 months.
Source: Florida Medicaid rule 59G-4.074 (Respiratory, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You see your doctor in person about sleep problems before your sleep test.
- A sleep test, at home or in a lab, shows sleep apnea at Medicare's level: 15 or more events an hour, or 5 to 14 with symptoms such as daytime sleepiness, high blood pressure or mood problems.
- Coverage starts with a 12-week trial. To keep it, you use the machine at least 4 hours a night on 70% of nights over 30 days in a row, and see your doctor again between day 31 and day 91 to confirm it's helping.
What your doctor needs to do
- See you before the sleep test and write down your symptoms (snoring, sleepiness, pauses in breathing).
- Order the sleep test and sign the order for the machine.
- See you again between day 31 and day 91 to confirm you're using it and it's helping.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your sleep test report, if you have it.
- Plan to use the machine every night from day one: the first 3 months decide continued coverage.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- In-person clinical evaluation by the treating practitioner before the sleep test (symptoms such as snoring, daytime sleepiness, observed apneas, choking or gasping, morning headaches; Epworth score, BMI, neck circumference and airway exam as applicable).
- Qualifying test (PSG or Type II, III or IV HST) on or after that encounter: AHI or RDI ≥ 15/hour (minimum 30 events), or 5–14/hour (minimum 10 events) with excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or history of stroke.
- Initial 12-week trial.
- Re-evaluation between day 31 and day 91 documenting benefit, plus objective adherence: ≥ 4 hours per night on 70% of nights in a consecutive 30-day period in the first 3 months.
Required documents
- Standard written order.
- Face-to-face evaluation note before the sleep test.
- Sleep study report interpreted by a qualified practitioner.
- Day 31–91 re-evaluation note and the adherence download (supplier collects the download).
Common denial reasons
- Sleep test done before the in-person clinical evaluation.
- AHI 5–14 without documented qualifying symptoms or conditions.
- No re-evaluation between day 31 and 91, or adherence under 4 hours on 70% of nights.
Source: LCD L33718 Positive Airway Pressure Devices · Policy article A52467. As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You've completed a sleep study within 30 days of the CPAP prescription.
- The sleep study report is signed and dated by a physician.
- CPAP is rented; supplies needed to run it are included in the rental.
- A BiPAP is considered only after CPAP has been tried without success.
What your doctor needs to do
- Order the sleep study.
- Write the CPAP prescription within 30 days of the study.
What to bring or ask for
- Your Florida Medicaid ID card.
- Your sleep study report.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- CPAP and BiPAP covered for recipients who completed a sleep study within 30 days of the prescription of the device.
- Sleep study reports signed and dated by a physician licensed under Chapter 458 or 459, F.S.
- BiPAP: unsuccessful results from CPAP first.
- Fee schedule: E0601 rental only, bundled code (supplies included during the rental).
- The QIO may also apply review criteria approved by AHCA (Authorization Requirements Policy s. 3.1).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Sleep study more than 30 days before the prescription.
- Report not signed and dated by a physician.
- BiPAP without a documented CPAP trial.
Source: Florida Medicaid rule 59G-4.074 (Respiratory, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You're confined to your bed or one room, or
- You live on one level of your home with no toilet on that level, or your home has no toilet.
- Extra-wide heavy-duty commodes: you weigh 300 pounds or more. Detachable arms: needed for transfers or extra width.
What your doctor needs to do
- Note why you can't get to a toilet: confined to bed or room, or no toilet on your level.
- Sign a written order.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your weight.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Patient is confined to a single room, to one level of the home with no toilet on that level, or to a home with no toilet facilities.
- Extra wide/heavy duty (E0168): weighs 300 lb or more.
- Detachable arms (E0165): arms needed to facilitate transfers, or the patient's body configuration requires extra width.
Required documents
- Standard written order.
- Notes documenting the confinement or lack of toilet facilities.
- Weight, for heavy-duty.
Common denial reasons
- Commode ordered for convenience or use over the toilet only, without confinement documented.
Source: LCD L33736 Commodes, Bed Pans and Urinals · NCD 280.1 DME Reference List. As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers commodes, including detachable or drop-arm commodes, when medically necessary.
- Usually one commode every 8 years for a standard commode.
What your doctor needs to do
- Write a prescription or certificate of medical necessity with your diagnosis and why you need it.
What to bring or ask for
- Your Florida Medicaid ID card.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Commodes (detachable or drop-arm) are a bathroom and toileting aid listed under 59G-4.076; usually covered when medically necessary.
- Fee schedule: E0163 all ages, 1 per 8 years; E0165 and E0168 1 per 3 years.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Prescription outside the 12-month / 21-day window.
- Commode already supplied within the limit.
Source: Florida Medicaid rule 59G-4.076 (Continence, Ostomy and Wound Care, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually not covered
What to know
- Original Medicare usually does not pay for shower chairs, tub benches, raised toilet seats or grab bars. It treats them as comfort, convenience or hygiene items rather than medical equipment.
- Many people buy these directly, and we can help you choose. Some Medicare Advantage plans include a bathroom-safety benefit; we can check yours.
What your doctor needs to do
- Nothing is needed for a direct purchase. If you need a commode instead, see the commode result.
What to bring or ask for
- Measurements of your tub or shower and toilet height help us pick the right item.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- NCD 280.1: bathtub seats, raised toilet seats (deny: convenience/hygienic, not primarily medical); grab bars (deny: self-help device, not primarily medical).
- Commodes are covered separately when the patient is confined to bed or room (see Commode).
Required documents
- None for Original Medicare (not a covered benefit).
Common denial reasons
- Billed to Original Medicare: denied as not primarily medical in nature.
Source: NCD 280.1 DME Reference List. As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Limited coverage: we check the exact item
Usually covered when…
- Florida Medicaid's 2026 fee schedule lists a raised toilet seat and a tub stool or bench, but not shower chairs, tub transfer benches or grab bars.
- Its policies exclude comfort, convenience and hygiene items. Some Medicaid health plans and long-term care programs cover more; we check yours.
What your doctor needs to do
- For a raised toilet seat: write a prescription with your diagnosis and why you need it.
What to bring or ask for
- Your Florida Medicaid ID card, and any health plan card.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Fee schedule 2026: E0244 raised toilet seat and E0245 tub stool or bench, all ages, 1 per 8 years. E0240 (bath/shower chair), E0247/E0248 (transfer bench) and E0241 (grab bar) not listed.
- Exclusion: personal comfort, convenience, hygiene or general sanitation items (59G-4.075 / 4.076 section 5.2).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Items not on the fee schedule (shower chair, transfer bench, grab bars) billed to straight Medicaid.
Source: Florida Medicaid rule 59G-4.076 (Continence, Ostomy and Wound Care, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You need to move (transfer) between the bed and a chair, wheelchair or commode.
- Without a lift, you would be confined to bed.
What your doctor needs to do
- Note that you need to transfer between the bed and a chair, wheelchair or commode, and that without a lift you'd be confined to bed.
- Sign a written order.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your weight, and who helps with transfers at home.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Transfer between bed and a chair, wheelchair or commode is required and, without the use of a lift, the beneficiary would be bed confined (basic criteria for E0630, E0635, E0639, E0640).
Required documents
- Standard written order.
- Notes documenting the transfer assistance needed and bed confinement without a lift.
Common denial reasons
- Notes don't state that transfers are required and that the patient would be bed-confined without a lift.
Source: LCD L33799 Patient Lifts. As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- Florida Medicaid usually covers a patient lift when moving you takes the help of more than one person.
- It comes with the seat, sling, straps and pads, and needs prior approval.
What your doctor needs to do
- Write a prescription or certificate of medical necessity noting that transfers need more than one person.
What to bring or ask for
- Your Florida Medicaid ID card.
- Your weight.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Portable lift used when the assistance of more than one person is necessary to move the recipient.
- Must include the necessary seat, sling, straps and pad(s).
- Fee schedule: E0630 and E0635 require prior authorization; 1 per 8 years.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- No documentation that more than one person is needed.
- Supplied without prior authorization.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of October 31, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Your doctor writes down a walking or balance problem that makes everyday tasks at home, like using the bathroom, dressing or getting to the kitchen, impossible, unsafe or very slow.
- You can use a cane or crutches safely.
- A cane or crutches are enough to solve the problem.
What your doctor needs to do
- See you and note exactly which daily tasks at home are hard and why.
- Note that you can use the cane or crutches safely and that they will help.
- Sign a written order.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your height, so we can size the cane or crutches.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Mobility limitation that significantly impairs one or more mobility-related activities of daily living (toileting, feeding, dressing, grooming, bathing) in customary locations in the home: prevents the task, puts the patient at heightened risk, or prevents finishing it in a reasonable time.
- The patient is able to safely use the cane or crutch.
- The functional mobility deficit can be sufficiently resolved by use of a cane or crutch.
- Underarm, articulating, spring-assisted crutch (E0117): medical necessity not established (denied).
Required documents
- Standard written order: patient name or MBI, order date, item description, quantity, practitioner name or NPI, practitioner signature.
- Medical record notes describing the mobility limitation in the home and that the patient can safely use the device.
Common denial reasons
- Vague notes such as "unsteady" without the tasks at home it affects.
- No statement that the patient can use the cane or crutch safely.
- Spring-assisted underarm crutch (E0117) billed.
Source: LCD L33733 Canes and Crutches. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Your doctor prescribes it as medically necessary.
- Canes and crutches come with their tips, pads and grips.
- Usually one standard cane a year, one quad cane every 3 years, and one pair of crutches every 2 years (2026 fee schedule).
What your doctor needs to do
- Write a prescription (or certificate of medical necessity) with your diagnosis and why you need it.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Medically necessary (rule 59G-1.010).
- Canes, crutches and walkers must include tips, pads and grips (59G-4.075 4.2.1).
- Fee schedule 2026: E0100 1 per year; E0105 1 per 3 years; E0110, E0112, E0114 1 per 2 years.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Prescription dated more than 21 days after delivery, or older than 12 months.
- Item already supplied within the fee-schedule limit.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Your wheelchair itself meets Medicare's rules. A cushion for a chair Medicare doesn't pay for is denied.
- A standard cushion: you have a manual wheelchair, or a power wheelchair with a sling or solid seat.
- A skin protection cushion: you have, or have had, a pressure sore where you sit, or you have reduced feeling there, or you can't shift your weight on your own.
- A positioning cushion or back: your body is significantly uneven when you sit (postural asymmetry).
- Your records describe the condition. Since October 2025 Medicare no longer needs a specific diagnosis code.
What your doctor needs to do
- Note the reason for the cushion: pressure sore history and location, reduced feeling, can't shift weight, or uneven posture.
- Or have a physical or occupational therapist do a seating evaluation that records it.
- Sign a written order for the cushion or back.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- The make and model of your wheelchair.
- Any recent therapy or seating evaluation.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- General use seat or back cushion: the beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back that meets Medicare coverage criteria.
- Skin protection seat cushion: covered wheelchair plus either a current or past pressure ulcer on the area of contact with the seating surface, or absent or impaired sensation in that area, or inability to carry out a functional weight shift.
- Positioning seat cushion, positioning back cushion and positioning accessories: covered wheelchair plus significant postural asymmetries.
- Combination skin protection and positioning seat cushion: meets the criteria for both.
- If the beneficiary doesn't have a covered wheelchair, the cushion is denied as not reasonable and necessary.
- Power wheelchair with a captain's chair seat (or a POV): headrests and other positioning accessories are denied.
- Since 10/01/2025 (LCD revision R13 and article A52505) skin protection and positioning cushions no longer require a diagnosis from the ICD-10 groups; the clinical condition must still be documented in the practitioner's notes or the LCMP (PT/OT) evaluation.
Required documents
- Standard written order with the six elements.
- Practitioner notes or a PT/OT seating evaluation documenting the qualifying condition (ulcer history and location, sensation, weight-shift ability, postural asymmetry).
- Documentation that the wheelchair base itself meets coverage criteria.
Common denial reasons
- Wheelchair base not covered, so the cushion is denied too.
- Skin protection or positioning cushion without the condition described in the record.
- Positioning accessories on a power chair with a captain's chair seat.
Source: LCD L33312 Wheelchair Seating · Policy article A52505. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- Florida Medicaid lists wheelchair cushions as covered pressure-care equipment.
- Most skin protection and positioning cushions and backs need prior approval, usually one every 3 years (2026 fee schedule).
- For a custom wheelchair, the cushion is part of the therapist's wheelchair evaluation.
What your doctor needs to do
- Write a prescription with the diagnosis and the reason for the cushion.
- Include notes or a therapy evaluation describing skin and posture.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Wheelchair cushions are decubitus care equipment under 59G-4.076 (4.2.3).
- Fee schedule 2026: E2601–E2608, E2611–E2616, E2620, E2621 require PA, 1 per 3 years; E2619 (seat cover) 1 per 3 years without PA.
- Customized wheelchairs: Custom Wheelchair Evaluation (AHCA Med Serv Form 015) lists the cushion, back and positioning components.
- The QIO may also apply review criteria approved by AHCA (Authorization Requirements Policy s. 3.1).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Cushion supplied before prior authorization.
- Another cushion supplied within 3 years.
Source: Florida Medicaid rule 59G-4.076 (Continence, Ostomy and Wound Care, Dec 2023) · Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Medicare pays for the wheelchair itself, and your records show you need each option.
- Elevating legrests: you can't bend your knee to 90 degrees (a condition, cast or brace), you have significant leg swelling that needs elevating, or you have a reclining back.
- Batteries: up to two at a time for a power wheelchair, sealed type. A lithium battery is usually replaced once every 3 years.
- Power tilt or recline: you qualify for a power wheelchair, a therapist does a specialty evaluation, and you are at high risk of pressure sores and can't shift your weight, or need it to manage muscle tone or spasticity.
What your doctor needs to do
- Note why you need each option (for example: leg swelling, can't bend the knee, can't shift weight).
- For power seating: refer you to a physical or occupational therapist for a specialty evaluation.
- Sign a written order that lists the options.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- The make, model and serial number of your current chair, if it's an add-on or replacement.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Options and accessories are covered when the beneficiary has a wheelchair that meets Medicare coverage criteria and the option or accessory itself is medically necessary.
- Elevating legrests (E0990, K0195): musculoskeletal condition or cast/brace that prevents 90-degree knee flexion; or significant lower-extremity edema requiring an elevating legrest; or meets the criteria for and has a reclining back.
- Batteries: up to two at any one time if required for a power wheelchair. Non-sealed batteries (E2358, E2360, E2362, E2364, E2372) are denied. Usual maximum replacement for a lithium battery (E2397) is one every 3 years.
- Power tilt and/or recline (E1002–E1010, E1012): meets power wheelchair criteria (L33789); specialty evaluation by a licensed/certified medical professional; supplier employs a RESNA-certified ATP specializing in wheelchairs; and high risk for pressure ulcers with inability to perform a functional weight shift, or the system is needed to manage increased tone or spasticity.
- Power seat elevation (E2298): meets Group 2 or Group 3 power wheelchair criteria and the seat elevation criteria in NCD 280.16 (see the complex rehab power wheelchair item).
Required documents
- Standard written order listing each option.
- Notes documenting the medical need for each option.
- For power seating: the specialty evaluation.
Common denial reasons
- Option billed when the wheelchair base isn't covered.
- Elevating legrests without edema, knee-flexion limit or reclining back documented.
- Non-sealed battery, or more than two batteries.
- Power tilt or recline without the specialty evaluation or a documented weight-shift or tone need.
Source: LCD L33792 Wheelchair Options/Accessories · NCD 280.16 Seat Elevation Equipment (CMS transmittal 12183). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Limited coverage: we check the exact item
Usually covered when…
- Florida Medicaid usually covers many wheelchair parts and options on its fee schedule, some with prior approval.
- Usually up to two elevating legrests every 4 years, and replacement batteries on a set schedule.
- Power tilt and recline need prior approval; combination systems are approved with a custom wheelchair request.
- Not covered: power attendant controls, wheelchair lifts, ramps and transit tie-downs.
What your doctor needs to do
- Write a prescription naming each option and the diagnosis.
- For power seating or a custom chair: refer you for a wheelchair evaluation by a licensed therapist or physiatrist.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- The make, model and serial number of your chair.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Fee schedule 2026: E0990 2 per 4 years; E0971 2 per 4 years; batteries E2360–E2365 4 per 3 years; E1002–E1005 (power tilt or recline) PA, 1 per 5 years.
- E1006–E1008 (combination tilt and recline) are priced by the QIO with custom wheelchair and wheelchair repair requests.
- Wheelchair rental includes armrests, backs, battery chargers, leg and footrests, wheels and tires.
- Not covered (59G-4.075 5.2): wheelchair power attendant control, lifts or ramps; transit tie-downs.
- The QIO may also apply review criteria approved by AHCA (Authorization Requirements Policy s. 3.1).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Excluded items (attendant control, lifts, ramps, tie-downs).
- Power seating supplied without prior authorization.
- Option replaced within its fee-schedule limit.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- You meet all of Medicare's power wheelchair basics (see the power wheelchair result).
- Your mobility problem comes from a neurological condition, a muscle disease (myopathy) or a skeletal condition you were born with.
- A physical or occupational therapist who doesn't work for us does a specialty evaluation, and our RESNA-certified ATP is directly involved in choosing your chair.
- Power tilt or recline: you're at high risk of pressure sores and can't shift your weight, or you need it to manage muscle tone or spasticity.
- Power seat elevation: the evaluation confirms you can use it safely at home, and you need it for transfers or to reach things for everyday tasks like toileting or dressing.
- Medicare approves the chair in advance (prior authorization).
What your doctor needs to do
- See you in person for a mobility exam, with mobility as a main reason for the visit.
- Refer you to a physical or occupational therapist for a specialty wheelchair evaluation, then sign and agree with it.
- Sign the written order before the chair is delivered, within 6 months after the exam.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- A list of what you can't do at home now, and how you get in and out of the chair.
- Your height and weight. We also check your home before delivery.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- General power wheelchair criteria (L33789), and the mobility limitation is due to a neurological condition, myopathy or congenital skeletal deformity (Group 3).
- Specialty evaluation by a licensed/certified medical professional (PT, OT or physician with specific training in rehab wheelchair evaluations) documenting the medical necessity for the chair and its special features; no financial relationship with the supplier.
- Supplier employs a RESNA-certified ATP who specializes in wheelchairs and has direct, in-person involvement in chair selection.
- Single or multiple power option bases (K0856–K0864): also need a non-standard drive control, or qualify for and use a power tilt/recline system, or a ventilator mounted on the chair.
- Power tilt/recline (L33792): high risk for pressure ulcers and unable to perform a functional weight shift, or needed to manage increased tone or spasticity.
- Power seat elevation (NCD 280.16, effective 05/16/2023; complex rehab power wheelchairs): specialty evaluation confirms the ability to safely operate it in the home, and one of: weight-bearing transfers to/from the chair in the home; a non-weight-bearing (e.g. dependent) transfer in the home; or reaching from the chair to complete one or more MRADLs in customary home locations.
- Power standing systems: no national coverage determination. As of mid-2026 CMS had not opened a national coverage analysis.
- Prior authorization required for PWC bases K0848–K0864 (CMS required PA list).
Required documents
- Face-to-face mobility examination by the treating practitioner; the note shows a major reason for the visit was a mobility exam.
- Written order prior to delivery (WOPD), dated within 6 months after the face-to-face.
- Specialty evaluation (PT/OT), with the treating practitioner's signed agreement where it forms part of the face-to-face.
- Supplier home assessment and detailed product description (supplier side).
- Documentation supporting each power seating option and accessory.
Common denial reasons
- Diagnosis not in the neurological, myopathy or congenital skeletal categories for a Group 3 base.
- Specialty evaluation missing, or done by someone with a financial relationship with the supplier.
- Order written before the face-to-face exam or more than 6 months after it.
- Tilt, recline or seat elevation without the documented functional need.
- Delivered before prior authorization was affirmed.
Source: LCD L33789 Power Mobility Devices · Policy article A52498 · LCD L33792 Wheelchair Options/Accessories · NCD 280.16 Seat Elevation Equipment (CMS transmittal 12183) · CGS (Jurisdiction C) DMEPOS prior authorization list. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- You can't walk, or your mobility is severely limited.
- Your records show you can't operate a manual wheelchair and can control a power chair on your own.
- A licensed therapist or physiatrist completes the custom wheelchair evaluation, listing each custom feature you need.
- Florida Medicaid approves it in advance. Power attendant controls aren't covered.
What your doctor needs to do
- Write a prescription or certificate of medical necessity with your diagnosis.
- Refer you for the custom wheelchair evaluation by a licensed therapist or physiatrist.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- Any recent therapy evaluation, and your height and weight.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Recipient is nonambulatory or has severely limited mobility; one wheelchair per maximum unit period.
- Customized chairs: Custom Wheelchair Evaluation (AHCA Med Serv Form 015) by the licensed therapist or certified physiatrist; valid six months from signature; prior authorization from the QIO.
- Documentation of the recipient's physical status (cognitive and physical abilities; mobility, coordination and strength; self-care and activity limitations), an itemized invoice, and a list of each customized feature required.
- Power wheelchairs: documentation of inability to operate a manual wheelchair and ability to independently control the power chair.
- Group 3 bases (K0848–K0864) and combination power tilt/recline (E1006–E1008) are priced by the QIO with custom wheelchair requests (fee schedule pricing guide).
- Not covered: customized wheelchair rentals; wheelchair power attendant control.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Form 015 missing or older than six months.
- No list of the customized features and why each is needed.
- No documentation the recipient can't use a manual chair or can control a power chair.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- You meet Medicare's manual wheelchair basics (see the manual wheelchair result).
- Ultralightweight chair: you use a manual wheelchair full time, or you need fitting and adjustments a lighter standard chair can't provide.
- Tilt-in-space chair: a therapist's specialty evaluation shows why you need it.
- A physical or occupational therapist who doesn't work for us does the evaluation, and our RESNA-certified ATP is involved in person.
- From October 28, 2026: an in-person visit with your doctor within 6 months before the order, and the signed order before delivery. Ultralightweight chairs also need Medicare's approval in advance.
What your doctor needs to do
- See you in person about your mobility, within 6 months before writing the order.
- Refer you to a physical or occupational therapist for a specialty wheelchair evaluation.
- Sign the written order before the chair is delivered.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- How many hours a day you spend in your chair, and your current chair's make and model.
- Your height and weight.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Basic manual wheelchair criteria (L33788): MRADL limitation in the home; not resolved by cane or walker; home access; regular use; not unwilling; and can self-propel safely or has a willing, able caregiver.
- Ultralightweight (K0005): full-time manual wheelchair user, or requires individualized fitting and adjustments for one or more features that can't be accommodated by a K0001–K0004 base.
- K0005 and tilt-in-space (E1161): specialty evaluation by an LCMP (PT, OT or practitioner with specific training in rehab wheelchair evaluations) documenting medical necessity and the special features; for K0005, routine activities and the features needed compared with a K0004. No financial relationship with the supplier (hospital-owned supplier exception).
- Supplied by a Rehabilitative Technology Supplier employing a RESNA-certified ATP specializing in wheelchairs, with direct, in-person involvement in selection.
- From 10/28/2026: K0002–K0007 and E1161 are on the required face-to-face (within 6 months before the order) and written-order-prior-to-delivery list; K0005 requires prior authorization nationwide.
Required documents
- Face-to-face encounter note within 6 months before the order (dates of service on or after 10/28/2026).
- Written order prior to delivery with the six standard elements.
- LCMP specialty evaluation.
- Prior authorization request (K0005, from 10/28/2026).
Common denial reasons
- K0005 without full-time use or individualized-fitting need documented.
- Specialty evaluation missing or done by someone with a financial tie to the supplier.
- Order dated after delivery, or face-to-face older than 6 months (from 10/28/2026).
- K0005 delivered before prior authorization was affirmed.
Source: LCD L33788 Manual Wheelchair Bases · Policy article A52497 · CGS manual wheelchair documentation checklist (rev. Oct 2026) · Face-to-face / written order before delivery list, effective Oct 28, 2026 (Noridian). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met, with prior authorization
Usually covered when…
- You can't walk, or your mobility is severely limited.
- Florida Medicaid's 2026 fee schedule lists an ultralightweight chair (one every 5 years).
- Chairs built for you, including tilt-in-space, need a therapist or physiatrist evaluation and prior approval.
What your doctor needs to do
- Write a prescription with your diagnosis.
- Refer you for the custom wheelchair evaluation by a licensed therapist or physiatrist.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- Your height and weight, and any recent therapy evaluation.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Recipient is nonambulatory or has severely limited mobility; one wheelchair per maximum unit period.
- Fee schedule 2026: K0005 1 per 5 years. E1161 is priced by the QIO with custom wheelchair requests.
- Customized chairs: Form 015 evaluation by the licensed therapist or certified physiatrist (valid six months), list of each customized feature, physical-status documentation and prior authorization.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Form 015 missing or older than six months.
- Another wheelchair supplied within the replacement period.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You own the equipment and still need it for your condition.
- The repair is needed to make it work again. Routine upkeep like cleaning and checking isn't covered.
- Usually no new order is needed, but your doctor's records from the last 12 months should show you still need the equipment.
- Parts and labor under warranty go through the warranty. If a repair would cost more than replacing the item, Medicare pays up to the replacement amount.
What your doctor needs to do
- Nothing new in most cases. If your last visit about this equipment was more than a year ago, we may ask your doctor for a recent note showing you still need it.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- The brand, model and serial number (often on a sticker under the seat or frame).
- What's wrong, when it started, and where you got the equipment.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Repairs to items the beneficiary owns are covered when necessary to make the item serviceable (Benefit Policy Manual, ch. 15, §110.2).
- The base item must meet the benefit category and be reasonable and necessary; if Medicare paid for it, medical necessity is established, but continued need must be documented.
- No new order is required for a repair; the treating practitioner's documentation of continued need must be on record within the preceding 12 months.
- Routine maintenance (testing, cleaning, regulating, checking) isn't covered. Payment can't exceed the cost of replacement for the remaining period of need.
- Warranty parts and labor aren't separately paid. Repairs to capped-rental items during the rental period and to oxygen equipment aren't separately paid.
- Labor is billed with K0739 per 15 minutes, within the DME MAC's allowance table; no payment for travel or pickup/delivery.
Required documents
- Practitioner documentation of continued medical need within the last 12 months.
- Supplier repair record: what was repaired, why each part was replaced, and labor time.
- Make, model and serial number of the item.
Common denial reasons
- No record of continued need in the last 12 months.
- Repair of rented equipment during the rental period.
- Routine maintenance billed as repair.
- Parts covered by warranty.
Source: Medicare Benefit Policy Manual, Chapter 15, §110.2 · CGS (Jurisdiction C) complex rehab repair FAQs. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Limited coverage: we check the exact item
Usually covered when…
- Florida Medicaid repairs equipment it provided, after the warranty ends, when the damage isn't from misuse or neglect.
- Repairs to rented equipment aren't paid separately; the rental covers them.
- Larger repairs usually need prior approval. We check your case.
What your doctor needs to do
- Usually nothing new. For a larger repair we may ask for a current prescription or note.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- The brand, model and serial number.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Maintenance and repair covered when: damage not due to misuse, neglect or wrongful disposition; warranty expired or doesn't cover it; and Florida Medicaid provided the equipment (59G-4.075 4.2.8; same in 4.074, 4.076, 4.072).
- Not covered: repairs and maintenance of rental equipment separately; parts or labor within the warranty; travel time and repair assessment time.
- By-report repairs: description, documentation of medical necessity, invoices, warranty and before-and-after descriptions to the QIO. Reimbursement up to 75% of the equipment's original cost.
- Repair labor has a yearly limit on the Florida Medicaid fee schedule; custom wheelchair repair parts are priced by the QIO.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Equipment not originally provided by Florida Medicaid.
- Item still under warranty.
- Damage from misuse or neglect.
Source: Florida Medicaid rule 59G-4.075 (Wheelchairs, Hospital Beds and Ambulatory Aids, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Your doctor documents breathing symptoms during sleep (such as daytime sleepiness, tiredness, morning headaches or shortness of breath) and one of these four conditions, with the test results Medicare asks for:
- A neuromuscular disease or severe chest-wall problem, with high carbon dioxide in a blood test while awake, or low oxygen during sleep (for neuromuscular disease, weak breathing-muscle test results also count).
- Central or complex sleep apnea, confirmed by an attended sleep study in a sleep lab that also shows the machine helps on your home settings.
- A hypoventilation syndrome, with high carbon dioxide while awake, breathing tests that don't show a COPD-type blockage, and carbon dioxide rising or oxygen dropping during sleep.
- Chronic respiratory failure from COPD, with high carbon dioxide in a blood test while awake (52 or higher) on your usual oxygen, when sleep apnea isn't the main cause (Medicare's national rule, NCD 240.9).
- To keep coverage after 3 months (the first three conditions): you use it at least 4 hours a day on average, and your doctor confirms it's helping, no sooner than day 61. For COPD: you use it at least 4 hours a day on at least 70% of days, and your doctor checks how it's working by month 6 and again in months 7 to 12.
What your doctor needs to do
- Document your symptoms (sleepiness, morning headaches, fatigue, shortness of breath).
- Order the tests your condition needs (blood gas, overnight oxygen, breathing tests or a sleep study).
- Sign a written order, and see you again after day 61 to confirm it's working.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Copies of your sleep study and blood test results.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Restrictive thoracic disorders: documented neuromuscular disease or severe thoracic cage abnormality; awake PaCO2 ≥ 45 mm Hg on prescribed FiO2, or sleep SpO2 ≤ 88% for ≥ 5 minutes (minimum 2-hour recording); for neuromuscular disease, maximal inspiratory pressure < 60 cm H2O or FVC < 50% predicted is also accepted; COPD does not significantly contribute.
- Central or complex sleep apnea: complete facility-based attended PSG confirming the diagnosis (CAHI ≥ 5/hour, central events > 50%) and showing significant improvement on the home settings.
- Hypoventilation syndrome (E0470): awake PaCO2 ≥ 45 mm Hg; FEV1/FVC ≥ 70%; and either a PaCO2 rise ≥ 7 mm Hg during sleep or on awakening, or SpO2 ≤ 88% for ≥ 5 minutes not caused by obstructive events (AHI < 5).
- Chronic respiratory failure consequent to COPD (NCD 240.9, eff. 06/09/2025; the LCD's severe COPD criteria were removed 06/09/2025): PaCO2 ≥ 52 mm Hg by arterial blood gas during awake hours on the prescribed FiO2, and sleep apnea is not the predominant cause of the hypercapnia (formal sleep testing not required if the treating clinician determines this).
- COPD, RAD with backup rate: also stable COPD (no increase in or new onset of more than one respiratory symptom for 2 or more days and no change in drug treatment in the 2 weeks before NIV), or hypercapnia persisting at least 2 weeks after hospitalization for an exacerbation that needed acute NIV; used as high-intensity therapy (IPAP ≥ 15 cm H2O, backup rate ≥ 14/min) by the end of month 6. RAD without backup rate: for patients who cannot tolerate high-intensity NIV or for whom a backup rate is medically inappropriate.
- COPD continued coverage (NCD 240.9): use ≥ 4 hours per 24-hour period on ≥ 70% of days in a 30-day period, with an evaluation by the end of month 6 (plus at least one outcome: PaCO2 < 46 mm Hg, a rising PaCO2 stabilized, PaCO2 down 20% from baseline, or improvement in headache, fatigue, dyspnea, confusion or sleep quality) and again in months 7–12; then ≥ 4 hours on ≥ 70% of days in each paid rental month.
- Continued coverage beyond 3 months (restrictive, CSA/CompSA, hypoventilation): re-evaluation no sooner than day 61, average use ≥ 4 hours per 24 hours, and a signed treating-practitioner statement of compliant use and benefit.
Required documents
- Standard written order.
- Notes documenting symptoms of sleep-associated hypoventilation and the qualifying condition.
- Qualifying test results (blood gas, oximetry, spirometry or PSG as applicable).
- Day-61-or-later practitioner statement of use and benefit (kept on file by the supplier).
- COPD: awake arterial blood gas on the prescribed FiO2, a statement that sleep apnea is not the predominant cause, and the month-6 and month-7–12 evaluations.
Common denial reasons
- Test values or conditions not documented.
- No continued-use statement after day 61.
- COPD with awake PaCO2 below 52 mm Hg, or no statement that sleep apnea is not the main cause of the hypercapnia.
- E0470 for obstructive sleep apnea submitted under these RAD criteria: E0470 for OSA is addressed in the PAP LCD (L33718), which requires a CPAP (E0601) tried and proven ineffective first.
Source: LCD L33800 Respiratory Assist Devices · NCD 240.9 Home NIPPV for chronic respiratory failure consequent to COPD · LCD L33718 Positive Airway Pressure Devices · CGS: Positive airway pressure devices webinar (Sept 19, 2024), E0470 for OSA under the PAP LCD. As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You've tried CPAP without success first.
- You've completed a sleep study within 30 days of the BiPAP prescription.
- The sleep study report is signed and dated by a physician.
- The machine is rented; supplies are included in the rental.
What your doctor needs to do
- Document that CPAP didn't work for you.
- Order the sleep study and write the prescription within 30 days of it.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- Your sleep study report.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- CPAP and BiPAP covered for recipients who completed a sleep study within 30 days of the prescription (59G-4.074 4.2.2.1).
- BiPAP: unsuccessful results from CPAP first.
- Sleep study reports signed and dated by a physician licensed under Chapter 458 or 459, F.S.
- Fee schedule 2026: E0470 and E0471 rental only, bundled (supplies included), 1 per month.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- No documented CPAP trial.
- Sleep study more than 30 days before the prescription.
- Report not signed and dated by a physician.
Source: Florida Medicaid rule 59G-4.074 (Respiratory, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You need the nebulizer to take an inhaled medicine that Medicare lists for your condition.
- For example: albuterol, ipratropium, budesonide and similar medicines for obstructive lung disease such as COPD; other medicines for cystic fibrosis, bronchiectasis or thick secretions.
- If none of your nebulizer medicines is covered, the machine isn't either.
- Medicine refills ship only after we check with you, up to 3 months at a time.
What your doctor needs to do
- Note your lung condition and the medicine you'll use in the nebulizer.
- Sign a written order for the nebulizer and the medicine, with dose and how often.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your list of breathing medicines.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Small volume nebulizer (A7003–A7005) and compressor (E0570) are considered for coverage when reasonable and necessary to administer a covered FDA-approved inhalation solution for its listed condition.
- Obstructive pulmonary disease (Group 8 ICD-10): albuterol, arformoterol, budesonide, cromolyn, formoterol, ipratropium, levalbuterol, metaproterenol, revefenacin.
- Cystic fibrosis: dornase alfa; cystic fibrosis or bronchiectasis: tobramycin; CF, bronchiectasis or ciliary dyskinesia: hypertonic saline; persistent thick secretions: acetylcysteine; HIV, pneumocystosis or transplant complications: pentamidine.
- Ensifentrine: add-on for COPD on dual LABA/LAMA or triple therapy with continued exacerbations or dyspnea.
- If no drug used with the nebulizer is covered, the compressor, nebulizer and accessories are denied.
- Refills: documented beneficiary request before dispensing; no more than a 3-month quantity.
- Final LCD L33370 and policy article A52466 (after reconsideration) apply to claims with dates of service on or after 02/01/2026 (DME MAC notice, Dec 18, 2025).
Required documents
- Standard written order for the equipment and each drug (drug, dose, frequency).
- Notes documenting the diagnosis the drug is covered for.
- Refill request documentation (supplier).
Common denial reasons
- Diagnosis doesn't match the drug's covered condition.
- Drug not covered, so the nebulizer is denied too.
- Refill shipped without a documented request.
Source: LCD L33370 Nebulizers · Policy article A52466 · Noridian: Nebulizers final LCD and RTC article published (Dec 18, 2025). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers nebulizers when medically necessary, with an administration kit (mouthpiece, cup, tubing).
- Usually one nebulizer every 2 years (2026 fee schedule).
- Your nebulizer medicines (for example albuterol, ipratropium or budesonide) are usually filled at a pharmacy under Medicaid's prescription drug benefit, not supplied with the machine.
What your doctor needs to do
- Write a prescription with your diagnosis and why you need the nebulizer.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Nebulizers covered with administration kits including hand-held mouthpiece; lid, jar and baffles; tubing; T-piece (59G-4.074 4.2.2.4).
- Compressor: covered when used with a nebulizer that provides at least 50 psi, or to support equipment that isn't self-contained.
- Fee schedule 2026: E0570 1 per 2 years.
- Inhalation solutions such as albuterol, ipratropium and budesonide are on the Florida Medicaid Preferred Drug List (eff. 10/01/2026), whose claims pay at the pharmacy counter: send drug prescriptions to a pharmacy. The DME claim covers the nebulizer, compressor and administration kit.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Nebulizer already supplied within 2 years.
- Nebulizer supplied from a physician's office with a financial interest in the provider.
Source: Florida Medicaid rule 59G-4.074 (Respiratory, Dec 2023) · Florida Medicaid DME fee schedule (2026) · Florida Medicaid Preferred Drug List (effective Oct 1, 2026). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You have trouble raising and clearing secretions because of one of these: cancer or surgery of the throat or mouth, swallowing-muscle problems, being unconscious or barely responsive, or a tracheostomy.
- Tracheostomy suction catheters: up to 3 a day when you have a trach and a covered suction machine.
- Oral suction catheters: up to 3 a week.
What your doctor needs to do
- Note why you can't clear secretions on your own and which condition causes it.
- Sign a written order for the machine and supplies.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your hospital discharge papers, if you're coming home with a trach.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Respiratory suction pump (E0600): difficulty raising and clearing secretions secondary to cancer or surgery of the throat or mouth; dysfunction of the swallowing muscles; unconsciousness or obtunded state; or tracheostomy. Other uses denied.
- Tracheal suction catheters (A4624): tracheostomy and a covered E0600 for tracheostomy suctioning; more than 3 per day denied.
- Closed-system catheters (A4605): same criteria plus a covered ventilator.
- Non-tracheal catheters (A4628) for oropharyngeal suctioning: more than 3 per week denied.
- Sterile water/saline (A4216, A4217): covered for clearing the catheter after tracheostomy suctioning, not for oropharyngeal suctioning.
- Gastric suction pump (E2000): unable to empty gastric secretions through normal GI function.
Required documents
- Standard written order.
- Notes documenting the qualifying condition and difficulty clearing secretions.
- Refill requests for catheters (supplier).
Common denial reasons
- Condition not one of the four listed.
- Tracheal catheters without a tracheostomy, or more than 3 a day.
- Saline billed for oral suctioning.
Source: LCD L33612 Suction Pumps · Policy article A52519. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers home suction machines for upper airway or stomach suction that can be used without a nurse present.
- Usually one machine every 2 years (2026 fee schedule).
What your doctor needs to do
- Write a prescription with your diagnosis and why you need suction.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- In-home suction machines for upper respiratory or gastric suction used without technical or professional supervision (59G-4.072 4.2.4).
- Fee schedule 2026: E0600 1 per 2 years (purchase or rental).
- The QIO may also apply review criteria approved by AHCA (Authorization Requirements Policy s. 3.1).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Machine already supplied within 2 years.
Source: Florida Medicaid rule 59G-4.072 (Specialized, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You have a tracheostomy.
- Supplies are usually covered up to set monthly amounts, for example care kits, and a new trach tube about every 3 months. More needs a reason in your records.
- A starter kit is usually covered only in the first two weeks after surgery.
- Refills ship only after we check with you, up to 3 months at a time.
What your doctor needs to do
- Sign a written order listing the trach supplies and how often they're changed.
- Note any reason you need more than the usual amount.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your trach tube brand, size and type.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Tracheostomy care or cleaning starter kit (A4625) covered following an open surgical tracheostomy; no longer necessary beginning two weeks post-operatively.
- Usual maximum quantities include: A4625 31 per month; A4623 and A4481 62 per month; A7520 and A7521 1 per 3 months; A7522 1 per 12 months.
- Quantities above the usual maximum need the reason clearly documented in the medical record.
- A7523 (shower protector) is a convenience item, not covered. A7527 (tube plug/stop) replaces a tube: A7520–A7522 billed with it are denied.
- Refills: documented beneficiary request; no more than a 3-month supply at home (1 month in a nursing facility).
Required documents
- Standard written order.
- Records supporting quantities above the usual maximum.
- Refill request documentation (supplier).
Common denial reasons
- Quantities above the usual maximum without a documented reason.
- Starter kit billed more than two weeks after surgery.
- Refills shipped without a documented request.
Source: LCD L33832 Tracheostomy Care Supplies. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers tracheostomy supplies when medically necessary.
- Your doctor's plan of care lists the type and number of supplies, how often you use them, and for how long. Quantities follow the 2026 fee schedule, for example trach tubes as medically necessary and up to 4 ties a month.
What your doctor needs to do
- Write a prescription with the diagnosis, the supplies and how often they're changed.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- Your trach tube brand, size and type.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Tracheostomy supplies are covered respiratory equipment (59G-4.074 4.2.3).
- Fee schedule 2026 examples: A7520, A7521 medical necessity; A7525 4 per month; A4623 60 per year; A4625 14 per medical event; A4629 31 per month.
- Plan of care must specify frequency of use, length of need, quantity and type (59G-4.074 s. 6.2). CMN or prescription dated within 21 days after services start and less than 12 months old.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Quantities above fee-schedule limits without approval.
- Supplies for recipients 21 and over living in a nursing facility.
Source: Florida Medicaid rule 59G-4.074 (Respiratory, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You have an ostomy (for example a colostomy, ileostomy or urostomy).
- How much is usually covered depends on the type of ostomy, up to set monthly amounts. More needs a reason in your records.
- Refills ship only after we check with you, no sooner than 10 days before you run out, and up to 3 months at a time.
What your doctor needs to do
- Sign a written order listing your pouches, barriers and accessories and how often you change them.
- Note the reason if you need more than the usual amount (for example leaks or skin problems).
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- The brand and product numbers you use now, and your stoma size.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Quantity is determined primarily by the type of ostomy; the LCD sets usual monthly or six-month maximums per code (e.g. A4357 2 per month; A5120 150 per six months).
- Greater quantities: the reason must be clearly documented in the medical record.
- Liquid barrier products A4369 and A5120 aren't billed together; continent stomas: no more than one such supply per day.
- Refills: contact the beneficiary and document an affirmative response no sooner than 30 days before the end of the current supply; deliver no sooner than 10 days before; no automatic shipping.
- No more than a 3-month supply at home (1 month in a nursing facility).
Required documents
- Standard written order with the items and quantities.
- Records supporting continued need and any quantity above the usual maximum.
- Refill request documentation and proof of delivery (supplier).
Common denial reasons
- Above-usual quantities without a documented reason.
- Refills shipped automatically or without a documented request.
- Products from incompatible systems billed together.
Source: LCD L33828 Ostomy Supplies · Policy article A52487. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers ostomy supplies when medically necessary.
- Quantities follow the 2026 fee schedule, counted per stoma.
- Supplies aren't shipped automatically: each refill needs your request on record.
What your doctor needs to do
- Write a prescription with your diagnosis, the supplies and quantities.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- The brand and product numbers you use now.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Ostomy supplies are covered medical supplies (59G-4.076 4.2.4).
- Fee schedule maximums are per stoma or fistula unless stated otherwise.
- Not covered: auto-refills of consumable ostomy products; provider must keep the recipient's refill requests.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Auto-refilled supplies without a recipient request.
- Quantities above fee-schedule limits without approval.
Source: Florida Medicaid rule 59G-4.076 (Continence, Ostomy and Wound Care, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Your records show a long-term bladder problem (urinary retention or incontinence) that needs catheters.
- Intermittent (straight) catheters: up to 200 a month.
- Sterile catheter kits only in certain cases: you live in a nursing facility, have a weakened immune system or a spinal cord injury, have documented reflux, or had two urinary infections in 12 months while using straight catheters.
- Indwelling (Foley) catheters: usually one a month, more if it's blocked, falls out or causes infections.
- External catheters can be used instead of an indwelling catheter for permanent incontinence.
What your doctor needs to do
- Note your bladder condition and the type of catheter you need.
- Write how many times a day you catheterize.
- Sign a written order with the catheter type, size and quantity.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- The brand, type and size of catheter you use now.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Intermittent catheters and kits (A4351–A4353, A4332, A4295–A4297): usual maximum 200 per month.
- Sterile intermittent catheter kit (A4353): beneficiary resides in a nursing facility; is immunosuppressed (e.g. transplant drugs, chemotherapy, AIDS, chronic oral corticosteroids) or has spinal cord injury; has radiologically documented vesico-ureteral reflux while on intermittent catheterization; or had two distinct UTIs within 12 months while on a prior intermittent program.
- Indwelling catheters: no more than one per month for routine maintenance; more with documented accidental removal, malfunction, obstruction or recurrent UTI.
- External catheters: covered for permanent urinary incontinence as an alternative to an indwelling catheter; male external catheters generally no more than 35 per month; denied when an indwelling catheter is also used.
- Permanence and diagnosis requirements are in policy article A52521.
- Final LCD L33803 (after reconsideration) applies to claims with dates of service on or after 01/01/2026: adds hydrophilic catheter codes A4295 and A4296 and kit code A4297, and lists spinal cord injury as an example of immunosuppression for sterile kits (A4297, A4353).
Required documents
- Standard written order with type, size and quantity.
- Notes documenting the condition, catheterization frequency, and any sterile-kit criterion.
- Refill request documentation (supplier).
Common denial reasons
- Sterile kits without a documented qualifying criterion.
- More than 200 intermittent catheters a month.
- External and indwelling catheters billed together.
Source: LCD L33803 Urological Supplies · Policy article A52521 · Noridian: Urological supplies final LCD and RTC article published (Nov 13, 2025). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers intermittent catheters when medically necessary; they must come with insertion kits.
- Usually up to 186 a month (2026 fee schedule).
What your doctor needs to do
- Write a prescription with your diagnosis, the catheter type and quantity.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- The brand, type and size of catheter you use now.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Intermittent catheters must include insertion kits (59G-4.076 4.2.4).
- Fee schedule 2026: A4351, A4352, A4353 186 per month, all ages.
- Not covered: auto-refills of consumable products.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Quantities above 186 per month without approval.
- Auto-refilled supplies.
Source: Florida Medicaid rule 59G-4.076 (Continence, Ostomy and Wound Care, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually not covered
What to know
- Original Medicare doesn't cover incontinence supplies or adult diapers. You pay the full cost.
- Some Medicare Advantage plans offer extra benefits for these supplies; we can check yours.
- If you also have Florida Medicaid, Medicaid may cover them: see the Florida Medicaid result.
What your doctor needs to do
- Nothing is needed for Original Medicare. If you have Florida Medicaid, your doctor writes a prescription (see that result).
What to bring or ask for
- Any Medicaid or Medicare Advantage card you have.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Original Medicare doesn't cover incontinence supplies or adult diapers (Medicare.gov coverage page).
- Catheters and other urological supplies are a separate benefit (see Urinary catheters).
Required documents
- None for Original Medicare (not a covered benefit).
Common denial reasons
- Billed to Original Medicare: not a covered benefit.
Source: Medicare.gov: Incontinence supplies & adult diapers. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers incontinence supplies for members age 4 and older: briefs, diapers, pull-ons, liners and pads, and undergarments.
- Up to 200 items a month in any combination (2026 fee schedule).
- The prescription must name the product type and quantity, and each refill needs your request on record.
What your doctor needs to do
- Write a prescription with your diagnosis, the product type (for example briefs or pull-ons), size and how many a month.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- Your size and the products you use now.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Covered for recipients age four years and older: disposable incontinence briefs, diapers, liners, shields, guards, pads, protective underwear, pull-ons, undergarments (59G-4.076 4.2.1).
- Fee schedule 2026: T4521–T4535 and related codes, ages 4–999, up to 200 units per month in any combination.
- Not covered: orders covering multiple individuals or not specific to a quantity or product type; auto-refills; sanitary wipes.
- Under 21: more than the limit may be approved if medically necessary (EPSDT).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Order not specific to product type and quantity.
- Auto-refills without a recipient request.
- More than 200 units a month without approval.
- Wipes billed.
Source: Florida Medicaid rule 59G-4.076 (Continence, Ostomy and Wound Care, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You need feedings through a feeding tube.
- A long-lasting problem with your digestive system, or a condition such as a nervous-system disease, keeps you from getting enough nutrition by mouth.
- Diet changes or oral supplements can't give you enough nutrition.
- The problem has to be long-lasting, not temporary.
- Medicare doesn't pay for formula you drink by mouth, only formula given through a feeding tube.
- A feeding pump is usually covered when your records explain why syringe or gravity feeding won't work, for example reflux or aspiration.
What your doctor needs to do
- Document why you can't get enough nutrition by mouth and that you need tube feeding.
- Write the order: formula, calories per day, feeding method (syringe, gravity or pump) and supplies.
- If a pump is needed, write down why.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your hospital discharge papers and current formula name, if you have them.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Enteral nutrition covered for a beneficiary who requires feedings via an enteral access device to provide sufficient nutrients to maintain weight and strength commensurate with overall health status.
- The beneficiary has permanent non-function or disease of the structures that normally permit food to reach the small bowel, or disease of the small bowel that impairs digestion and absorption, or another condition (e.g. CNS disease) that prevents adequate oral intake.
- Adequate nutrition must not be possible by dietary adjustment and/or oral supplements.
- Pump (B9002): medical necessity documented, e.g. gravity feeding unsatisfactory due to reflux and/or aspiration; otherwise denied.
- Test of permanence (A58833): the beneficiary must have a permanent impairment; met when the medical record, including the treating practitioner's judgment, indicates the impairment will be of long and indefinite duration. Enteral nutrition for temporary impairments is denied as non-covered, no benefit.
- Orally administered enteral nutrition products, related supplies and equipment are denied as non-covered, no benefit (A58833). Products administered only orally are coded A9270; add the BO modifier when listed enteral nutrients are given by mouth.
Required documents
- Standard written order with formula, calories and method of administration.
- Notes documenting the condition, why oral intake is inadequate, and tube placement.
- Pump justification, when a pump is ordered.
Common denial reasons
- Records don't show why oral nutrition isn't adequate.
- Pump without documented reason gravity or syringe feeding is unsatisfactory.
- Formula taken by mouth (no feeding tube): non-covered, no benefit.
- Record shows a temporary impairment, so the test of permanence isn't met.
Source: LCD L38955 Enteral Nutrition · Policy article A58833 Enteral Nutrition. As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers formulas, including tube-feeding formulas, when a medical condition keeps you from getting enough nutrition from regular food and drink.
- Feeding pumps and supply kits are usually covered. On the 2026 fee schedule the pump rental and pump supply kit are listed for members under 21.
- Regular store-bought foods, thickeners and baby food aren't covered.
What your doctor needs to do
- Write a prescription with your diagnosis, the formula, amount per day and feeding method.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- Your current formula name and amount per day.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Covered for recipients with a medical condition that prevents adequate nutrition through regular food and beverage: orally ingested formulas; enteral and parenteral formulas (59G-4.077 4.2.1).
- Enteral and parenteral pumps and infusion supplies covered; feeding supply kits include a one-month supply of items needed to start.
- Fee schedule 2026: B4034 and B4036 all ages, 31 per month; B4035 (pump supply kit) and B9002 (pump, rental) ages 0–20; formulas (e.g. B4150, B4152, B4154) 930 units per month.
- Not covered: commercially available food products, food thickeners, baby food, products for fluid/electrolyte replacement, bodybuilding or weight reduction.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Commercially available food products or thickeners.
- Quantities above 930 formula units per month without approval.
- No recipient or caregiver reorder request on file.
Source: Florida Medicaid rule 59G-4.077 (Enteral and Parenteral Nutrition, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You have diabetes and your doctor prescribes the meter or monitor and how often to test.
- Test strips and lancets: usually up to 100 every 3 months if you don't use insulin, up to 300 every 3 months if you do. More needs a visit within 6 months and a check that you're testing that often.
- Continuous glucose monitor (CGM): you use insulin, or have a history of problem low blood sugars, and your doctor saw you (in person or by Medicare-approved telehealth) within 6 months before ordering it.
- To keep the CGM covered, your doctor sees you every 6 months to confirm you're using it.
What your doctor needs to do
- Write the order with the testing frequency, or the CGM.
- For a CGM: see you within 6 months before ordering, note insulin use or problem lows, then see you every 6 months.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Whether you use insulin, and how many times a day you test.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Blood glucose monitor and supplies: diabetes, and the practitioner concludes the beneficiary or caregiver is adequately trained (prescription for supplies and testing frequency).
- Usual utilization every 3 months: non-insulin users up to 100 strips and 100 lancets; insulin users up to 300 strips and 300 lancets. Higher quantities need an in-person or Medicare-approved telehealth visit within the prior 6 months and adherence verification every 6 months.
- CGM initial coverage: diabetes; adequately trained; prescribed per FDA indication; insulin-treated or history of problematic hypoglycemia (defined in the policy article); and a visit within 6 months before ordering.
- CGM continued coverage: every 6 months, an in-person or telehealth visit documenting adherence to the CGM regimen and treatment plan.
Required documents
- Standard written order (testing frequency, or CGM).
- Notes: diabetes, insulin use or hypoglycemia history, and the 6-month visit for CGM.
- Testing logs, when above-usual quantities are ordered.
Common denial reasons
- Above-usual strips without a 6-month visit and adherence check.
- CGM without insulin use or documented problematic hypoglycemia.
- No 6-month follow-up visit for continued CGM coverage.
Source: LCD L33822 Glucose Monitors. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Limited coverage: we check the exact item
Usually covered when…
- Prior authorization usually required; we check your case.
- On the 2026 DME fee schedule, CGM supplies are listed for members under 21 with prior approval. Meters and test strips aren't on the DME fee schedule.
- Blood sugar meters, test strips and CGMs usually come from a pharmacy under Florida Medicaid's diabetic supply benefit, not from a medical equipment supplier. Your pharmacy can tell you which brands are preferred.
What your doctor needs to do
- Write a prescription with your diagnosis and testing frequency; we confirm how your plan handles it.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Fee schedule 2026 (DME): A9276 and A9277/A9278 ages 0–20, PA.
- Blood glucose meters and test strips are not listed on the 2026 DME fee schedule.
- Diabetic Supply Services Coverage Policy (59G-4.252, Sept 2024): covers supplies on the Diabetic Supply Preferred Product List (traditional meters 1 per year, test strips 200 per month, listed CGMs) with a diabetes diagnosis and a prescription; providers are pharmacies and enrolled practitioners; claim type is a point-of-sale transaction; PBM authorization is required before dispensing.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- CGM supplies without prior authorization.
Source: Florida Medicaid DME fee schedule (2026) · Florida Medicaid Diabetic Supply Services Coverage Policy (59G-4.252, Sept 2024) · Florida Medicaid Diabetic Supply Preferred Product List (Oct 1, 2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Open leg ulcer: gradient compression stockings are covered only when they're used to treat an open venous stasis ulcer.
- Lymphedema: since January 1, 2024, Medicare usually covers daytime and nighttime compression garments, wraps, bandaging and accessories when a doctor, nurse practitioner, PA or clinical nurse specialist documents a lymphedema diagnosis.
- Usually up to 3 daytime garments for each affected body part every 6 months, and 2 nighttime garments every 2 years. Sooner if lost, damaged or your size changes.
- Plain support stockings, or stockings to prevent a problem, are usually not covered: for example vein problems without an open ulcer, or after an ulcer has healed.
What your doctor needs to do
- Document the open venous ulcer, or the lymphedema diagnosis.
- Write the order naming the garment: type, compression level, body part and quantity. We confirm what we can supply.
- If a custom-fitted garment is needed, note why a standard one won't fit or work.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your doctor's order with the garment type and compression level.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Surgical dressing benefit: gradient compression stockings A6531, A6532 (and wrap A6545) are covered in the treatment of an open venous stasis ulcer. Non-covered: venous insufficiency without stasis ulcers, prevention of stasis ulcers, prevention of recurrence after healing, lymphedema without ulcers (under this benefit).
- Lymphedema compression treatment items (Social Security Act §1861(s)(2)(JJ); dates of service on or after 01/01/2024): standard and custom-fitted daytime and nighttime garments, wraps, bandaging supplies (phases 1 and 2) and accessories, covered only for the treatment of lymphedema.
- Lymphedema diagnosis documented by an MD, DO, NP, PA or CNS; documentation from a PT or OT alone doesn't satisfy this.
- Custom-fitted garments: the record documents why a custom item is needed instead of a standard one.
- Replacement: up to 3 daytime garments or wraps per body area every 6 months; up to 2 nighttime garments per body area every 2 years; sooner for loss, theft, irreparable damage, or a change in condition.
- Every lymphedema claim line carries an SC, GA, GY or GZ modifier (from 01/01/2026), plus RT/LT.
Required documents
- Standard written order: garment type, compression, body part, quantity, and the six standard elements.
- Notes documenting the open venous stasis ulcer (size, location) or the lymphedema diagnosis by an MD/DO/NP/PA/CNS.
- Reason for a custom-fitted garment, when ordered.
Common denial reasons
- Compression stockings for venous insufficiency without an open ulcer, or for prevention.
- Lymphedema diagnosis documented only by a therapist.
- More garments than the replacement schedule without a qualifying reason.
Source: LCD L33831 Surgical Dressings · Policy article A54563 · CMS: Lymphedema Compression Treatment Items · CGS: Lymphedema compression treatment items, coding and billing (rev. Mar 2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Limited coverage: we check the exact item
Usually covered when…
- Check with us: Florida Medicaid's 2026 fee schedule lists gradient compression stockings, but its policies set no specific criteria. We confirm your case.
What your doctor needs to do
- Write a prescription with the diagnosis, garment type, compression level and quantity.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Fee schedule 2026: A6530–A6535 all ages, 8 stockings per year; A6536–A6541 8 per year.
- No compression-specific criteria in rules 59G-4.072 through 59G-4.077.
- The QIO may also apply review criteria approved by AHCA (Authorization Requirements Policy s. 3.1).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- More than 8 stockings per year without approval.
Source: Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- You need the pump to give a specific medicine Medicare lists for your condition at home.
- Examples include deferoxamine for iron overload, certain chemotherapy, morphine for hard-to-control cancer pain, certain antiviral and antifungal drugs, heart-failure drugs given continuously, pulmonary hypertension drugs, and immune globulin under the skin for immune deficiency.
- Insulin pumps have their own criteria, including a doctor's visit at least every 3 months.
What your doctor needs to do
- Note your diagnosis and the medicine, dose and schedule.
- Sign the written order for the pump, the medicine and supplies.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your discharge papers or infusion orders.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Pumps E0779, E0780, E0781, E0788, E0791 covered for listed drug/indication pairs, including: deferoxamine (chronic iron overload); chemotherapy for unresectable primary hepatocellular carcinoma or colorectal cancer; morphine for intractable cancer pain; other listed anticancer agents, narcotic analgesics, acyclovir, foscarnet, amphotericin B, ganciclovir; inotropes for advanced heart failure; epoprostenol/treprostinil for pulmonary hypertension; subcutaneous immune globulin for PID or CIDP; ziconotide; levodopa infusion for certain Parkinson's disease; blinatumomab.
- Continuous subcutaneous insulin (E0784): specific C-peptide, autoantibody or prior-therapy criteria and visits at least every 3 months.
- Denied: home heparin infusion for thromboembolic disease or PE; compounded drugs NOC (J7999) with a pump; infusion controllers.
- Refills: documented beneficiary request; no more than a 3-month quantity.
Required documents
- Standard written order (WOPD for certain base items).
- Notes documenting the diagnosis and the drug, dose and schedule.
- Refill request documentation (supplier).
Common denial reasons
- Drug or indication not on the LCD's list.
- Home heparin infusion for thromboembolic disease.
- Compounded drug billed as NOC with the pump.
Source: LCD L33794 External Infusion Pumps. As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Limited coverage: we check the exact item
Usually covered when…
- Prior authorization usually required; we check your case.
- On the 2026 fee schedule, infusion pump rentals are listed in the nutrition section for members under 21.
What your doctor needs to do
- Write a prescription with the diagnosis, the drug or nutrition and the schedule.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- 59G-4.077 4.2.2: enteral and parenteral pumps and infusion supplies covered.
- Fee schedule 2026: E0779, E0781 (and E0776, E0780, E0791) rental, ages 0–20, bundled.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Pump billed for an adult without approval.
Source: Florida Medicaid rule 59G-4.077 (Enteral and Parenteral Nutrition, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Knee brace: you walk and your knee is weak or deformed and needs support; or after a recent knee injury or surgery; or your exam shows the knee is unstable; or for knee arthritis on one side, with an adjustable (unloader) brace you're willing to wear.
- Ankle-foot brace: you walk, your foot or ankle is weak or deformed and needs support, and the brace can help you function. Night splints: plantar fasciitis, or an ankle contracture that can be corrected with stretching.
- Back brace: to reduce pain by limiting movement, to help healing after a spine injury or surgery, or to support weak back muscles or a curved spine.
- Some knee and back braces need Medicare's approval in advance.
- We fit off-the-shelf braces only. We don't make custom braces or prostheses — ask your doctor for a referral to an orthotist/prosthetist.
What your doctor needs to do
- Examine you and note why you need the brace. For a knee brace for instability, record the exam tests you did.
- Sign a written order for the brace (and side: left or right).
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- Your height and weight, and the measurements your doctor took, if any.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Knee orthoses (L33318, rev. eff. 01/25/2026): L1810/L1812 ambulatory with knee weakness or deformity requiring stabilization; L1830 recent injury or surgery; L1832/L1833 recent injury or surgery, or ambulatory with knee instability; L1843/L1845/L1851/L1852 ambulatory with objective instability, recent injury or surgery, or medial/lateral tibiofemoral OA with pain or reduced function, varus/valgus adjustment and willingness to use it.
- Objective knee instability must be supported by the physical exam, including the joint laxity tests performed.
- AFOs used during ambulation (L33686): ambulatory, weakness or deformity of the foot and ankle, requires stabilization for medical reasons, potential to benefit functionally.
- Static/night AFO (L4396/L4397): non-fixed plantar flexion contracture (≥ 10° passive dorsiflexion) expected to correct, interfering with function, with an active stretching program; or plantar fasciitis.
- Spinal orthoses LSO/TLSO (L33790): to reduce pain by restricting trunk mobility; to facilitate healing after injury or surgery of the spine or related soft tissue; or to support weak spinal muscles and/or a deformed spine.
- Prior authorization (CMS required list, CGS Jurisdiction C): L0631, L0637, L0639, L0648, L0650, L0651, L1832, L1843–L1846, L1851, L1852, L1932, L1951; from 10/28/2026 also L1833, L0456, L0457 and L0486 (Federal Register 2026-15446; CMS).
- From 10/28/2026: face-to-face within 6 months and written order prior to delivery for L1833, L1906, L1933, L1952, L0456, L0457, L0486.
Required documents
- Standard written order (WOPD for listed codes).
- Exam notes documenting the qualifying condition; for knee instability, the laxity tests performed.
- Face-to-face note within 6 months, for the codes on the required list.
- Prior authorization affirmed before delivery, for codes on the prior authorization list (including L1833, L0456, L0457, L0486 from 10/28/2026).
Common denial reasons
- Knee instability claimed without documented exam findings.
- AFO for a person who doesn't walk (except night splints that meet their criteria).
- Fixed contracture or foot drop without contracture for a night splint.
- Brace delivered before prior authorization where required.
Source: LCD L33318 Knee Orthoses · LCD L33686 Ankle-Foot/Knee-Ankle-Foot Orthosis · LCD L33790 Spinal Orthoses: TLSO and LSO · CGS (Jurisdiction C) DMEPOS prior authorization list · CMS: Prior authorization process for certain DMEPOS items (update of 07/29/2026) · Federal Register 2026-15446: Master List, F2F/WOPD and Required Prior Authorization List updates, effective Oct 28, 2026 · Face-to-face / written order before delivery list, effective Oct 28, 2026 (Noridian). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- Florida Medicaid usually covers orthotic braces on its fee schedule when medically necessary.
- The supplier fits the brace and handles adjustments and replacements for the first 6 months.
- We fit off-the-shelf braces only. We don't make custom braces or prostheses — ask your doctor for a referral to an orthotist/prosthetist.
What your doctor needs to do
- Write a prescription with your diagnosis, the brace and side.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
- Your height and weight.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Orthotic devices covered per the fee schedule (59G-4.073); custom only when a less costly alternative isn't available.
- Provider responsible for all needed adjustments, modifications and replacements for the first six months after delivery; measurement and fitting records kept.
- Fee schedule 2026 examples: L1833 and L1851 2 per 2 years; L1902 and L1932 2 per year; L0450 1 per medical event; L0627 1 per 2 years; L0648 2 per lifetime.
- Not covered: non-prescription shoe inserts; devices that don't fit.
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Brace replaced within the fee-schedule limit.
- Adjustments in the first six months billed separately.
Source: Florida Medicaid rule 59G-4.073 (orthotic devices, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 4, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Usually covered when the criteria are met
Usually covered when…
- After surgery: for pain in the first month after the operation.
- Long-lasting pain (not low back pain): the pain has lasted at least 3 months, other treatments were tried and didn't work, and you try the unit for at least a month first. Medicare buys it if your doctor confirms it's helping long term.
- Medicare doesn't cover TENS for chronic low back pain.
What your doctor needs to do
- Note the location and cause of the pain, how long you've had it and what treatments you've tried.
- Order a trial of at least a month and check how it's working before ordering purchase.
What to bring or ask for
- Your Medicare card and any secondary insurance card.
- A list of treatments you've already tried for the pain.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Acute post-operative pain: covered for 30 days (one month's rental) from the day of surgery.
- Chronic pain other than low back pain: present at least three months; other appropriate modalities tried and failed; rental trial of at least one month monitored by the treating practitioner; purchase covered when the practitioner determines likely significant long-term benefit.
- Chronic low back pain: denied as not reasonable and necessary (NCD 160.27).
Required documents
- Standard written order.
- Notes documenting pain location, duration, prior treatments, and trial results before purchase.
Common denial reasons
- TENS for chronic low back pain.
- Purchase without a documented trial and benefit.
- No record of other treatments tried.
Source: LCD L33802 Transcutaneous Electrical Nerve Stimulators (TENS). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Limited coverage: we check the exact item
Usually covered when…
- Prior authorization usually required; we check your case.
- Florida Medicaid lists TENS units as covered specialized equipment, but the 2026 fee schedule has no code for them.
What your doctor needs to do
- Write a prescription with the diagnosis and why a TENS unit is needed.
What to bring or ask for
- Your Florida Medicaid ID card.
- If you're in a Medicaid health plan, that plan's card: its rules apply instead.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
Criteria checklist
- Transcutaneous and neuromuscular electrical nerve stimulators covered (59G-4.072 4.2.7).
- No TENS code (E0720, E0730) on the 2026 DME fee schedule; items not listed need QIO prior authorization (E1399).
- The QIO may also apply review criteria approved by AHCA (Authorization Requirements Policy s. 3.1).
Required documents
- Written prescription or Certificate of Medical Necessity (CMN): less than 12 months old and dated within 21 days after services start.
- A CMN states the diagnosis, prognosis, reason for the equipment and estimated length of need.
- Prescriber's printed name, dated signature and license number or NPI.
Common denial reasons
- Supplied without prior authorization.
Source: Florida Medicaid rule 59G-4.072 (Specialized, Dec 2023) · Florida Medicaid DME fee schedule (2026). As of November 1, 2026. A summary, not the full rule. Meeting these points does not guarantee payment.
Medicaid health plans usually follow Florida Medicaid's criteria, often with prior authorization.
Each plan (Sunshine Health, Simply, Molina, Staywell and others) sets its own approval steps and paperwork. We check your specific plan, request any approval it needs, and tell you what to expect before anything is ordered.
Baseline shown: Florida Medicaid's own criteria. Your plan may add its own forms or prior authorization.
Medicare Advantage plans usually follow Original Medicare's criteria, often with prior authorization.
Plans such as Wellcare, Devoted and Sunshine Health can add approval steps or require an in-network supplier. We check your specific plan and handle the approval request.
Baseline shown: Original Medicare's criteria. Your plan may require prior authorization or its own form.
Commercial plans usually follow Medicare-style criteria, often with prior authorization.
Employer and individual plans each have their own medical policies, deductibles and approval rules. We check your specific plan and tell you any cost up front.
Baseline shown: Original Medicare's criteria, which most commercial policies resemble. Your plan's own policy applies.
Not sure what you have? That's fine: we check for you.
Call us with your insurance card in hand and we'll look up your plan, tell you which rules apply and what your doctor needs to send.
Baseline shown: Original Medicare's criteria. We'll confirm which rules apply to your plan.
We check every request, item by item
Tell us what you're looking for — we carry far more than this list.
What almost every item needs
- A standard written order: patient name or Medicare number, order date, item description, quantity, the practitioner's name or NPI, and the practitioner's signature. For Florida Medicaid: a prescription or certificate of medical necessity less than 12 months old, dated within 21 days after services start, with the diagnosis.
- Recent visit notes that describe the condition and why the item is needed.
- Patient demographics and a copy of the insurance card or face sheet.
- Height and weight, when the item depends on them (wheelchairs, beds, lifts, walkers, braces).
How to reach us
- Regular equipmentFax (561) 245-5443
- Complex rehabFax (561) 861-7763
Doctor's office? The referral pre-check has a general checklist.
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.
We check every request, item by item
Tell us what you're looking for — we carry far more than this list.
General requirements (almost every item)
- A standard written order: patient name or Medicare number, order date, item description, quantity, the practitioner's name or NPI, and the practitioner's signature. For Florida Medicaid: a prescription or certificate of medical necessity less than 12 months old, dated within 21 days after services start, with the diagnosis.
- Recent visit notes that describe the condition and why the item is needed.
- Patient demographics and a copy of the insurance card or face sheet.
- Height and weight, when the item depends on them (wheelchairs, beds, lifts, walkers, braces).
Where to send it
- Regular equipmentFax (561) 245-5443
- Complex rehabFax (561) 861-7763
Coverage depends on your plan, your doctor's order and your medical records. This is a plain-language summary, not a decision. We verify every case before anything is ordered.