Understanding your prescription for equipment

An order is not the same as a prescription pad

For medication, a prescription is a fairly short document. For durable medical equipment, the order is only half of it — the other half is the supporting documentation in your medical record, and that is what plans actually adjudicate against.

This surprises people. The order can be perfect and the claim can still be denied because the chart note behind it does not establish medical necessity.

What a written order generally contains

• Your name.
• A description of the item — specific enough to identify it, including the side (left or right) for anything bilateral.
• The quantity, and for supplies the quantity per period.
• The prescriber's name and NPI.
• The prescriber's signature and the date they signed it.
• For some items, the length of need.

What the chart note has to do

The note from your face-to-face encounter needs to make the need obvious to a reader who has never met you. ‘Patient requests walker’ does not. ‘Patient reports two falls in the past month, unsteady gait on examination, unable to ambulate safely without support, cane tried and insufficient’ does.

It is not that your doctor is doing anything wrong. It is that the note was written for clinical purposes and is now being read for a different purpose entirely.

If you have been denied

• Ask what the denial reason actually says — there is a difference between ‘not medically necessary’, ‘documentation insufficient’, ‘same or similar on file’ and ‘not a covered benefit’. Only the last one is a wall.
• Ask your supplier which specific document or sentence was missing.
• Ask your prescriber's office to address that specific point in an addendum or a new note.
• Ask about the appeal route and the deadline, which is usually shorter than people expect.

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