How to Get Your DME Needs Covered Through Workers’ Comp: A Medicare Biller’s Guide

A Medicare Biller’s Guide: How to Get Your DME Covered Through Workers’ Comp 

If you’ve been injured on the job and need medical equipment, getting it paid for can be confusing. As a Medicare biller with experience navigating both federal and state systems, I’m here to explain exactly how to get Durable Medical Equipment (DME) approved through Workers’ Compensation—without the runaround.

➡️ Need help fast? Visit www.protherapysupplies.com to speak with a DME specialist. We’ll walk you through it step by step.

What Is DME and Why It Matters in a Workers’ Comp Case

Durable Medical Equipment (DME) includes medically necessary items like:

• Walkers, canes, crutches
• Wheelchairs (manual or power)
• Hospital beds
• Orthopedic braces
• CPAP machines
• TENS units
• Prosthetics or orthotics

If your injury happened at work, your employer’s Workers’ Compensation insurance is responsible for covering medically necessary equipment. But here’s the catch: the approval process is nothing like Medicare or private insurance.

Step 1: Get a Prescription from Your Treating Physician

Workers’ Comp won’t pay for anything that isn’t tied directly to your work injury. So first, your treating doctor (who must be authorized under the Workers’ Comp system) needs to write a detailed prescription or order for the DME. This should include:

• Type of equipment
• Medical necessity
• How long it's needed
• Diagnosis or injury code (ICD-10)

Step 2: Submit to the Workers’ Comp Adjuster

Next, your DME provider (or your case manager) must submit the prescription and documentation to the Workers’ Comp claims adjuster for review.

Unlike Medicare, which often allows same-day processing, Workers’ Comp moves slower. Approval can take days or even weeks depending on:

• State laws
• Complexity of your case
• Responsiveness of the adjuster
• Whether the DME provider is in-network

🔑 Pro tip: Work with a DME supplier experienced in Workers’ Comp cases. They know how to speak the adjuster's language and avoid denials.

Step 3: Authorization Must Come First

Do not try to pay out of pocket expecting reimbursement later. With Workers’ Comp, authorization must come before delivery. No pre-authorization = no payment.

Also, don’t assume Medicare will cover it as a backup. Medicare is a secondary payer and won’t pay if Workers’ Comp is liable—even if it’s delayed.

Step 4: Delivery and Billing

Once approved, the DME supplier will deliver the equipment and bill the Workers’ Compensation insurance directly. You should not receive a bill.

Behind the scenes, we submit a CMS-1500 form with all required documentation and billing codes. One mistake here can delay payment by months.

What If It Gets Denied?

If your DME request is denied:

• Ask your doctor to submit more documentation
• Request a Utilization Review
• In some states, you can request a hearing or mediation

You have rights. Don’t let the system wear you down.