I have a client who is trying to claim reimbursement for his Sonicare Toothbrush that was purchased by his dentist. I was wondering since this isn't typically something that is covered by insurance companies, is it eligible for reimbursement? I just thought that I would get some input on the subject since it is a toothbrush and you can't normally claim reimbursement for an "over the counter" toothbrush, so I don't see why this would be covered too, but please provide some input for me, and correct me if I am wrong in thinking that this is not covered for reimbursement.

You posted that it was "purchased by his dentist". Assuming that you really meant "from his dentist", I wonder what was the reason for the purchase? Was it part of a specific treatment program for a specified disease?
Was it part of a general maintenance program?

I think that the difference between this case and an OTC purchase needs to be clarified.

My FSA Reimbursement matrix says regarding battery powered toothbrushes - "Possibly, but only if prescribed to treat a specific dental ailment".

His dentist recommended that he purchase the toothbrush. We are trying to get ahold of him to find out if it was for a medical reason or just to better clean his teeth. If it is for a medical reason and he gets a letter from the dentist is it covered then, or is it just flat out not reimbursable? Please let me know.

Good grief! "Recommended"?
My doc might recommend I take two aspirin, or even "prescribe" an over-the-counter medication, but that does not mean it is eligible for a medical deduction or covered in a flex plan.
Just deny it.

We had the same scenario last year and the TPA accepted it with a RX from the dentist.

pax

A physician could write a prescription for an otc medication just to make it eligible and to certify the medical necessity. Take a look at some of the Rev Rulings and other guidance issued in the last 2 years regarding weight-loss, cayenne pepper, Christian Scientist practitioners, wheel chair accessible vehicles, stop-smoking treatment etc. to see what the IRS position is.

As the IRS points out it is not the fact that it is prescription or OTC but whether or not it is for the treatment etc etc of a eligible condition.

Not to open a can of worms here, but there is a distinction between drugs and non-drugs.

For drugs, the drug cannot be one that can be obtained over the counter. Thus, even if a Dr. prescribes it, it's not reimbursable. For example, ibuprofin can be obtained over the counter. If a Dr. prescribes a high dosage ibuprofin pill, it's not reimbursable even though the higher dosage horse size pill can only be obtained with a prescription. The reason is because the drug itself can be obtained over the counter. The reason for this IRS position is because of the wording in IRC 213. Having stated that, many TPAs don't bother looking for this when processing claims.

Anything other than drugs is subject to the "but for" test (this was how an IRS representative described the test). "But for" a specific medical condition, would the item (e.g., therapy, swimming pool, electric toothbrush, I even heard of a claim for a breast pump) be necessary. This is a very subjective test and I think the majority of TPAs would find something in writing from a Dr. sufficient to reimburse the claim.

As an FSA TPA, I would require that there be a specific condition in place to warrant or treat with the use of the purchased item. This might be that he has periodontal disease, which can be treated in a number of ways including the use of this special equipment. Remember that there is a difference between medical equipment/supplies and OTC medicines. (people seem to get that mixed up a lot!) There is always danger that a personal use item doesn't not meet certain tests, the "but for" test should be applied. That is, the ee would not have this expense, but for the specific condition...A written notice from the doctor would be absolutely necessary, indicating why it is necessary. Only after an ee has gone through those knds of hoops, would I consider reimbursing. (I'll bet the ee didn't consider this expense when estimating figures during the open enrollment, so perhaps he could wait and submit other claims during the plan year and hold that til the end...)