Mealtime Partners, Inc.

Medical Necessity of Assistive Dining Equipment

During the following months we will cover topics relating to public and private healthcare insurance coverage for equipment that facilitates independent eating for individuals who are unable to self-feed. Although we will specifically address independent eating, much of the information applies to any equipment that aids independence for any activities of daily living (or, ADL’s)

One of the most basic requirements for obtaining insurance coverage for any equipment is that it is medically necessary for the individual requesting it. In this Newsletter we will address some of the ways medical necessity can be established. Private insurance company’s definitions of medical necessity vary from policy to policy. For private insurance coverage it is necessary to check each policy to establish the medical necessity requirements of the specific policy. Some private insurance policies consider dining equipment as a medical necessity, while others don’t.

Even though Medicare and Medicaid both provide healthcare coverage they are governed by different regulations. Currently Medicare regulations exclude funding dining aids. However, Medicaid will, if medical necessity is established, fund dining equipment. Because neither Medicare or Medicaid provide a precise definition of medical necessity it must be deduced from Medicaid regulations and associated court rulings that dictate what Medicaid should cover as being medically necessary.

Medicaid - Federal law indicates that the primary goal of Medicaid is to provide medical assistance to persons in need and to furnish them with rehabilitation and other services to help them “attain or retain capability for independence and self-care”. (The Social Security Act, US Code: Title 42, 1396, states: “rehabilitation and other services to help such families and individuals attain or retain capability for independence or self-care should be provided by Medicaid”.) Therefore, attaining independence or self-care is identified as medically necessary within the scope of the federal law. In the case of dining equipment, if an individual will attain independence at meal and snack times through the use of dining equipment, and being able to feed them self will allow them to contribute substantially to their self-care, the equipment is a medical necessity.

Additionally, the Early and Periodic Screen, Diagnosis, and Treatment (EPSDT) program (which is part of Medicaid, and provides services to children from birth through age 21) guidelines require that a state must provide to Medicaid beneficiaries under age 21, any service among those listed in the Medicaid Act, including optional services, whether or not the service is included in the state’s Medicaid Plan. Under EPSDT (42 U.S.C 1396d(a)(4)(B, 1396d(r)(5)), state Medicaid programs must cover “necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects and physical and mental illnesses and conditions”. Services must be covered if they correct, compensate for, or improve a condition, or prevent a condition from worsening even if the condition cannot be prevented or cured. This portion of the law establishes that healthcare to ameliorate defects is considered a medical necessity.

However, Medicaid administrators do not always agree with the intent of the laws stated above. As a result there have been various court rulings when states have denied claims. The necessity of durable medical equipment (DME) coverage by Medicaid has been refined through legal judgments since Medicaid was first enacted. Some examples of court rulings relevant to the medical necessity of DME are:

Texas Medicaid agreed in the Alberto N. Settlement Agreement (6:99-cv-00459-LED-HWM, 2005) that DME is medically necessary when it is required to correct or ameliorate disabilities or physical and mental illness or conditions.” To “ameliorate” a condition or illness does not mean that the condition or illness has to “improve”. DME is medically necessary when it ameliorates the effects of diseases. In other words, beneficiaries should receive whatever services, including DME that are necessary to maintain his or her health in the best possible condition.

In Meyers v Reagan the Eighth Circuit Court (776 F.2d 241, 243, Eighth Circuit, 1985) reasoned that obtaining or retaining the capability for independence is the primary goal of Medicaid.

Starkweather v Wing (662 N.Y.S.2d 658,659 [N.Y.A.D. 4 Dept. 1997) supported the claim for a wheelchair for a child, to “increase the independence and functional ability of the petitioner, and to prevent the development of learned helplessness”.

In Fred C. vs. Texas Health and Human Services Commission, et al., the court determined: “the item is medically necessary because it is needed by a recipient who has a serious impairment to: enhance well being, prevent further impairment, increase self-care, or reduce care provided by others (self-care is defined as the ability of the recipient to take care of personal needs, e.g. eating, dressing, walking, talking, or using the device unassisted. Less care or reduced care by others is defined as the ability of the recipient to use a minimum of assistance to take care of personal needs).”

As can be derived from the court rulings, for appropriate individuals, the medical necessity case can be made for dining equipment by establishing that the equipment allows the individual to attain or retain capability for independence or self-care. It does not require that the individual become 100% independent in performing self-care, only that they can substantially contribute. At mealtimes, dining equipment can facilitate an individual feeding themselves every bite of food for a meal. Their caregiver only need prepare, cut up and serve the food. After the food is served, the individual is independent for the rest of the meal. The fact that it may make life more convenient for the caregiver is irrelevant if the primary reason for the equipment is for increasing the independence of the user.

Conclusions. A wide variety of durable medical equipment (DME) is established as being a medical necessity. Many items are assigned a Healthcare Common Procedures Code System (HCPCS) code and the medical necessity of these items is usually well accepted. For other equipment, especially new equipment, the medical necessity must be established for each client and an insurance coverage determination (i.e., prior approval or predetermination) should be sought before equipment is provided.

In many cases initial requests for coverage are denied. However, that should not be considered final. The reason for the denial should be examined and if the reason is unwarranted (review the laws, etc., cited above) an appeal should be submitted. When agreement cannot be reached between Medicaid and a client, a Fair Hearing should be requested to allow an officer, rather than Medicaid, to evaluate the merits of the claim. A claim should not be abandoned without a struggle! This statement applies even more strongly in states that have not previously seen new varieties of assistive technology/medical equipment.

Medicaid has provided funding for Mealtime Partner Dining Systems in several states. Medicaid only funds DME that is a medical necessity. Therefore, a Mealtime Partners Dining System must be considered a medical necessity for individuals who cannot self-feed and are capable of utilizing the equipment to facilitate their mealtime independence.