Letters to the Editor

DME woes

The article on durable medical equipment requests (“DME requests pose practice problems, “ ACP Internist, July/August 2014) barely scratches the surface of the hassle these new requirements pose for internists. Precise language is apparently required to get authorization, to the point that without a template, internists need to resubmit their notes or insert an addendum, requiring additional paperwork. The rules also keep changing. Now, I have to schedule patients just for a “face-to-face” visit to be sure I've documented every item in the ever-increasing list of requirements. What a waste of time for me and my patients.

Howard Homler, MD, FACP
Carmichael, Calif.

As a recently retired endocrinologist, I signed thousands of DME requests, mainly for diabetes monitoring supplies and “diabetic” shoes. It was extremely common for the supplier to try to sneak in another item or two, such as gauntlets (whatever they are), heating pads, back braces, and even more substantial items. On occasion I would investigate, and invariably the supplier had suggested the item (or a list of items) to the patient, indicating that Medicare would cover them (assuming the doctor would sign).

This is obviously a backward process. Medicare should stop using suppliers that persist in this underhanded behavior. Meanwhile, if I got a request for a back brace with the diabetic shoe form, I wouldn't try to find out what size brace the patient needs. If the item wasn't discussed at an office visit, I would deny it. At most, the patient could be sent a message indicating that if he or she truly felt the item was medically necessary, the need would have to be discussed at an office visit and documented (usually the patient didn't really need the item).

On a related topic, I feel Medicare makes authorizing diabetic testing supplies too time-consuming and cumbersome. A diagnosis of diabetes should be adequate to justify test strips, without the doctor having to fill out a full-page form with ancient questions (e.g.,”Is the device intended for home rather than office use?”). For a patient on an intensive insulin regimen, 3 strips per day is not enough. And if a type 2 diabetic wants to check more than once a day (before and after selected meals, for example), he shouldn't be discouraged from doing so.

On the other hand, I feel Medicare makes it too easy for patients to get certain other items. As soon as Medicare decides an item will be covered, an industry grows up to supply and promote it to patients, whether they need it or not. The aforementioned “diabetic” shoes provide such an example. A small number of diabetic patients truly need prescription shoes. However, most patients who get the expensive prescription shoes, perhaps justified by a callus (you can always find one) and an absent ankle jerk, could do just fine with a good pair of over-the-counter shoes. But patients feel they are entitled to the shoes because Medicare covers them, and other diabetics get them.

And heating pads—don't get me started.

Richard E. Kleinmann, MD, FACP
Belmont, N.C.