Private health insurance pays for assistive technology based on the criteria for coverage listed in the policy. Assistive technology devices must meet criteria for medical necessity and durable medical equipment. Criteria may vary from policy to policy, so it is important to refer to the policy. General interpretations are as follows:

• Medical necessity means that the device is prescribed by a physician; used to restore or approximate normal function of a missing, malformed, or malfunctioning body part; directly related to a diagnosed medical condition; and expected to improve the user’s ability to function.
• Durable medical equipment (DME) means that the device can withstand repeated use; is primarily or customarily used to serve a medical purpose; generally is not useful to an individual in the absence of illness or injury; and is appropriate for use in the home.

Most health insurance policies require prior approval for durable medical equipment. Prior approval is not a guarantee of payment. The prior approval process will be stated in the benefits booklet and may include the following steps:

• Get a medical prescription for the device from the doctor.
• Provide information supporting medical necessity from a qualified medical professional or team of professionals. Some types of assistive technology may require an evaluation. The supportive information needs to explain the person’s condition and why the device is needed, a description of the device with details explaining needed features, an explanation of how the device will improve the individual’s functional ability. Use the language stated in the policy to support the need for the equipment.
• Find out the method of payment accepted by the medical equipment supplier. Some vendors will accept a statement of prior approval; however, others require either a purchase order or a check before processing the claim.
• An insurance claim is not processed until the equipment has been received. Depending on the method of payment accepted, the individual may have to purchase the device and then be reimbursed.
• Some equipment suppliers may file the paperwork. Others may require the individual to handle everything.
• If prior approval is denied, there is an appeals process. The time limit for appeals and the process for appealing the denial should be explained in the benefits booklet.

For information about funding resources and strategies, contact:

Annette Lauber, Funding Specialist, North Carolina Assistive Technology Project, 1110 Navaho Drive, Suite 101,Raleigh, NC 27609-7322,

(919) 850-2787(voice/TDD), [email protected]