Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to hold you harmless for the Home therapy; enteral nutrition via pump; 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment services coded S9342. We decided that the Plan does not have to waive the coinsurance for the .  
 
You asked the Plan to pay for Home therapy; enteral nutrition via pump; administrative services, professional 
pharmacy services, care coordination, and all necessary supplies and equipment services coded S9342 provided 
on January 1, 2020, January 15, 2020, February 1, 2020, February 27, 2020, March 1, 2020, April 10, 2020, 
and May 1, 2020 and to waive the coinsurance for the enteral formula coded B4152 provided on January 20, 
2020, February 27, 2020, and April 10, 2020. You say that you disagree with the plan's decision. The Plan says 
that the services were processed correctly per your plan benefits. 
 
We decided that the Plan has to hold you harmless for the Home therapy; enteral nutrition via pump; 
administrative services, professional pharmacy services, care coordination, and all necessary supplies 
and equipment services coded S9342. 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were provided these items by a contract provider. The file does not show that the Plan provided notice that 
the services coded S9342 would not be covered. Under Medicare rules, this means these services are 
considered approved by the Plan. 
 
Therefore, we decided that the Plan has to hold you harmless for the Home therapy; enteral nutrition via pump; 
administrative services, professional pharmacy services, care coordination, and all necessary supplies and 
equipment services coded S9342 provided on January 1, 2020, January 15, 2020, February 1, 2020, February 
27, 2020, March 1, 2020, April 10, 2020, and May 1, 2020. 
 
We also decided that the Plan does not have to waive the coinsurance for the enteral formula coded 
B4152 provided on January 20, 2020, February 27, 2020, and April 10, 2020. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each Medicare-covered item for durable medical equipment and related supplies. Therefore, we 
decided that the Plan does not have to waive the coinsurance for the enteral formula coded B4152 provided on 
January 20, 2020, February 27, 2020, and April 10, 2020. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.