Medicare 5-Year Replacement Rule for DME and When Early Replacement is Covered

When it comes to Medicare billing, the rules can feel like a maze — especially when durable medical equipment (DME) is involved. At A2Z Billings, we’ve seen how one misunderstood policy can delay payments or create compliance issues. One of the most common questions providers ask us is about Medicare’s 5-year replacement rule for DME — what it means, when replacements are allowed, and what’s actually covered.

What Is the 5-Year Rule for Medicare DME?

The 5-year rule is Medicare’s way of setting a “reasonable life span” for most durable medical equipment. In short, Medicare assumes that most DME items should last at least five years from the date they’re first delivered to the patient. That means:

• Medicare usually won’t pay for a new item until the old one has hit the 5-year mark.
• The clock starts when the equipment is delivered — not when it’s prescribed.
• During that time, repairs and maintenance are covered, but full replacement usually isn’t.

It’s Medicare’s way of balancing patient care with cost control. But there are some exceptions, which we’ll get into shortly.

How Often Does Medicare Replace DME?

The simple answer is: every five years — unless there’s a good reason to replace it sooner. Here’s how Medicare looks at different scenarios:

Situation	Eligible for Early Replacement?
Equipment lost or stolen	Yes, with documentation (like a police or insurance report)
Damaged beyond repair (fire, flood, accident)	Yes, if proof is provided
Patient’s medical needs have changed	Yes, with a new prescription
Equipment worn out from normal use	Not until after 5 years
Switching suppliers or locations	No, unless medically necessary

  In short, the 5-year mark isn’t set in stone — it’s flexible when backed by solid documentation and medical need.

Medicare DME Replacement Guidelines

Medicare is looking at three main components when it comes to DME replacement: medical necessity, proper documentation, and supplier discretion.

Medical Necessity:

Your provider must indicate that you still need the equipment or that your condition justifies a different piece of equipment.

Documentation:

Documentation must accompany the claim for proper delivery, with the order from a legitimate medical provider, and validation. If the equipment is reported stolen or destroyed, then documentation must include a police report or insurance report.

Accredited Supplier:

Suppliers must be enrolled with Medicare and have the proper accreditation to bill for DMEPOS (Durable medical equipment, prosthetics, orthotics, and supplies).  When all three things are established, you are generally ok for reimbursement.

Medicare Repair and Replacement of DME

Not every piece of equipment lasts the full five years — especially items used daily like wheelchairs, CPAP machines, or oxygen tanks. Medicare knows this, which is why repairs are often covered when it’s cheaper to fix than replace.

Repairs:

Medicare Part B covers the labor and parts needed to fix medically necessary DME.

Replacement:

•  Covered if the equipment:
•  Can’t be repaired cost-effectively
•  Was lost, stolen, or destroyed
•  Is no longer suitable due to a change in the patient’s condition

As long as the provider keeps proper documentation, Medicare will typically reimburse these costs without issues.

Five Criteria for Medicare’s Definition of DME

To qualify for coverage, an item must meet all five of Medicare’s official DME criteria: Durable: Can withstand repeated use. Medical Purpose: Used to treat or manage a health condition. Not Useful Without a Medical Need: The item is specifically for people with a medical condition. Used at Home: Designed for home use, not hospital-only equipment. Long-Term Use: Expected to last at least three years. If a device doesn’t fit this definition, Medicare won’t cover it — even if it seems helpful to the patient.

List of Durable Medical Equipment Covered by Medicare

Here are some of the most common types of DME that Medicare Part B covers when prescribed for home use:

• Wheelchairs (manual or power)
• Walkers, crutches, and canes
• Oxygen supplies and equipment
• CPAP and BiPAP machines
• Nebulizers and inhalation accessories
• Hospital beds and specialized mattresses
• Blood glucose meters and test strips
• Patient lifts
• Suction pumps
• Infusion pumps and feeding equipment

Each of these requires a valid prescription and proof that the patient needs it for daily living.

List of Durable Medical Equipment Covered by Medicaid

DME Medicaid coverage varies from state to state, although most allows coverage based on Medicare guidelines. Typical DME covered by Medicaid includes:

• Wheelchairs and scooters
• Orthotic and prosthetic devices
• Oxygen and respiratory equipment
• Home hospital beds
• Diabetic care supplies
• Safety equipment for bathing or toileting (in some states)

It’s best to check your state’s Medicaid policy for exact coverage and documentation requirements.

What DME Is Not Covered by Medicare

Medicare has a very limited definition for what it considers to be medical necessity. Most items will not be covered in the following categories: 

• Disposal Items (i.e gloves, catheters) 
• Comfort or Domicile (evil purifier, humidifier, recliner) 
• Exercise Equipment (i.e treadmills, weights, bikes) 
• Domicile Modification (i.e. ramps, grab bars, lifts) 
• Items for Personal Comfort (i.e. heating pads, foot massager) 

If the item could be used if there is not a medical need, there will be a good chance it will not be approved.

Medicare 5-Year Replacement Rule Exceptions and Policy Updates

While the Medicare 5-year rule sets a standard replacement timeline, there are clear Medicare 5-year replacement rule exceptions that allow earlier coverage. These include loss, theft, irreparable damage, or a documented change in medical condition. Providers should also understand that DME treatment guidelines are updated regularly, typically through CMS transmittals, LCDs, and policy updates issued several times per year. Asking how often are DME treatment guidelines updated? is critical, because outdated rules can quickly lead to denials. Staying aligned with the most recent CMS guidance ensures replacement claims meet current medical necessity and documentation standards.

Medicare Durable Medical Equipment Fee Schedule

Every year, CMS updates its DME Fee Schedule, which lists how much Medicare pays for each covered device. The rate depends on:

• The type of equipment
• The patient’s location
• Competitive bidding outcomes

You can find the current schedule on the CMS website. Understanding it helps providers bill accurately and know what to expect in reimbursements.

DMEPOS Competitive Bidding and Medicare Provider Participation Rules

The DMEPOS competitive bidding program directly impacts how much Medicare reimburses for certain equipment in designated areas. Suppliers must bid to provide DME at set rates, and claims outside approved contracts may be denied. Additionally, Medicare participating provider rules require suppliers to be enrolled, accredited, and compliant with CMS billing standards to receive reimbursement. Providers should note that Medicare replacement plans (Medicare Advantage) may apply different billing rules, and billing rules for Medicare replacement plans for chiropractic services or other specialties can vary significantly. Always verify plan-specific requirements before submitting replacement claims.

Medicare Replacement Plans, State-Specific Rules, and Insurance Clarifications

Medicare replacement plans—also known as Medicare Advantage—are offered by private insurers and may follow rules that differ from Original Medicare. A common question is: is Golden Rule Insurance a Medicare replacement? Golden Rule is not a Medicare replacement plan; it primarily offers short-term and supplemental coverage. Additionally, some providers ask about Medicare 5-year replacement rule California—while Medicare rules are federal, California suppliers must also follow state licensing and competitive bidding requirements. Always confirm whether replacement requests fall under Original Medicare or a Medicare Advantage plan before billing.

When Early DME Replacement Is Covered

Early replacement is allowed when:

• The equipment is lost, stolen, or destroyed.
• It’s damaged beyond repair.
• The patient’s medical condition changes.
• The 5-year useful lifetime has expired.

As always, documentation is the deciding factor. A clear doctor’s order and proper supplier notes make the difference between approval and denial. The Medicare Durable Medical Equipment (DME) 5-year rule is designed for patients to have access to safe and long-lasting equipment. This rule provides everyone involved an advantage; however, sometimes interpreting the language can be challenging. Understanding what constitutes replacement DME, how to request and submit for reimbursement, and under what conditions will ultimately save time and money and be less stressful.  Here at A2Z Billings, we employ a team of billing specialists who focus their time on DME claims alone. From the initial claim submission, reviewing for compliance, and ensuring DME billing is compliant and reimbursed promptly, we can help. If your organization believes understanding the DME 5-year rule and managing the sheer volume of denials due to that rule takes too much of your valuable time, we’re here to help you simplify the process.