Paying for DME and medical supplies

What counts as durable medical equipment

Medicare’s consumer definition of DME is the one most suppliers and insurers still use as their common reference point, even outside Medicare itself. Equipment counts as DME when it is: durable (it can withstand repeated use), used for a medical reason, typically only useful to someone who is sick or injured (not something a person without the condition would also want), and used in your home. For complex bodies specifically, that usually means wheelchairs and scooters, walkers, hospital beds, standers and positioning equipment, feeding pumps, suction machines, and CPAP or other respiratory equipment.

Tennessee’s own Medicaid rule lists durable medical equipment as a covered TennCare benefit category in its own right, “covered as medically necessary.” Depending on the item, you may be required to rent before you buy, required to buy outright, or given a choice — ask the supplier which applies to a specific item before you agree to anything.

Who is involved

More people touch a DME request than most families expect going in:

• The prescribing clinician (a doctor or nurse practitioner) writes the order or prescription that starts the process.
• A therapist — often occupational, physical, or speech therapy, depending on the equipment — evaluates the actual functional need and typically writes or contributes to the letter of medical necessity.
• An ATP (Assistive Technology Professional), a certification through RESNA, often gets involved for complex items like custom wheelchairs and seating, matching the specific equipment to the specific person.
• The supplier bills the insurer or TennCare, delivers the equipment, and handles repairs going forward.
• The insurer or TennCare managed-care plan decides what’s authorized and what isn’t.

A simple item like crutches might only involve two of these. A custom power wheelchair usually involves all five.

Prior authorization and the letter of medical necessity

Prior authorization is your insurer’s or TennCare plan’s requirement to approve an item in advance, before they’ll pay for it. It can take real time, so ask about it as soon as equipment is discussed, not after it’s already been ordered.

A letter of medical necessity (LMN) is written by the prescribing clinician or evaluating therapist, based on their own examination — not something a parent or caregiver drafts. A strong one is specific rather than generic and generally covers: the diagnosis, the actual functional need the equipment addresses, why a lower-cost or standard alternative won’t meet that need, and how long the need is expected to last. Ask the clinician or therapist directly what their letter will say, and whether it names the specific item being requested.

Why the supplier matters

A valid order and an approved prior authorization can still lead to a denial if the equipment comes from the wrong supplier. Many plans, including TennCare MCOs, require DME to come from a specific network of enrolled suppliers — ordering from an out-of-network supplier can mean paying the full cost yourself or being refused reimbursement, even when the item itself was clearly appropriate.

Ask your plan directly which suppliers are in-network for this specific item, not just whether a supplier generally “takes” your insurance — network status can vary by product line within the same company.

If a request or claim is denied

Denials happen, sometimes for a genuine coverage reason and sometimes on a paperwork technicality — read the denial letter closely for the specific reason given before assuming the worst.

TennCare: a denied, reduced, or stopped service can be appealed as a medical appeal — by mail, fax, or online through TennCare Connect. TennCare aims to decide standard appeals within about 90 days, and urgent appeals in about a week. Call TennCare Member Medical Appeals at 1-800-878-3192 for help filing or to ask about an expedited review.

Private insurance: you have the right to an internal appeal, asking the insurer to conduct a full review of its own decision (sped up automatically for urgent cases), and then the right to an external review by an independent third party if the internal appeal doesn’t resolve it — at that point, the insurer no longer has the final say.

Either way, it’s reasonable to ask the same clinician to resubmit with more specific documentation instead of, or in addition to, filing a formal appeal.

Private insurance plus TennCare

Some families have both: private insurance as the primary plan, and TennCare as secondary coverage through Katie Beckett. In that situation, the private plan is generally billed first, and TennCare can pick up copays, deductibles, or therapy and equipment costs the primary plan limits or excludes — this pairing is often the difference between rationing equipment and just getting it.

“Coordination of benefits” is just the term for the two plans working out who pays what, and in what order, for a given claim. The details are plan-specific, so ask both plans directly how coordination works for a particular item rather than assuming.

What TennCare and waiver programs can pay for

TennCare covers medically necessary DME directly, as a covered benefit category under its own Medicaid rules.

For members under 21, TennCare Kids — Tennessee’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program — is built to catch and treat needs more comprehensively than routine adult coverage, on top of checkups, screenings, and immunizations.

For people enrolled in ECF CHOICES (TennCare’s program for people with intellectual or developmental disabilities), TennCare’s own comparison materials list “Assistive and Enabling Technology” and “Minor Home Modifications” among the covered services for several of its benefit groups. Limits apply per person per year — ask your DDA case manager or TennCare health plan for the current limit rather than assuming a figure from anywhere else, including this page.

The DDA Family Support Program is a separate, flexible state grant — not a waiver — that explicitly lists specialized equipment among what its yearly funding can cover, for people not already receiving comprehensive home-and-community-based services.

Borrowing, reusing, and charitable funding

Not everything has to be new or insurance-funded. The Tennessee Technology Access Program (TTAP), run by the Department of Human Services, offers device demonstration (hands-on trial before you commit), short-term device loan, and a device reutilization program that matches donated equipment with people who need it — statewide, and free to use. Call 1-833-772-8347.

The STAR Center runs its own reuse and loan program for assistive technology and equipment, with staff based in Jackson, Memphis, Nashville, Murfreesboro, Knoxville, and Chattanooga; tours, demonstrations, and reuse services are free. Call 1-800-464-5619.

Beyond state programs, some national and regional charities, disease- or diagnosis-specific foundations, and civic organizations fund equipment case by case. Availability and eligibility change often and vary by organization, so ask your therapist, DME supplier, or a medical social worker which ones are currently taking Tennessee applications rather than relying on an old list.

• Is this item covered under our plan, and does it need prior authorization first?
• Which suppliers are in-network for this specific item, not just in-network generally?
• Exactly what does the letter of medical necessity need to say?
• Do we need to rent before we can buy, and if so, for how long?
• If TennCare is secondary here, how does coordination of benefits work for this item?
• If this is denied, what's the appeal process and how long does it take?
• Is there a loan, reuse, or reimbursement option if this isn’t covered at all?
• Who do we call if the equipment breaks or needs to be replaced later?