Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the portable oxygen concentrator on April 27, 2019.
We decided that the Plan does not have to waive the coinsurance for the oxygen concentrators and portable
oxygen concentrators.
You asked the Plan to waive the coinsurance for the oxygen concentrators and portable oxygen concentrators.
You say that you were never notified that you would have to pay for your equipment. The Plan says that you
have been charged the correct cost sharing amount.
We decided that the Plan has to waive the coinsurance for the portable oxygen concentrator on April 27,
2019.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not submit the Explanation of Benefit for the portable oxygen
concentrator on April 27, 2019. Therefore, the Plan has not shown that the coinsurance amount you are being
asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive
the coinsurance for the portable oxygen concentrator on April 27, 2019.
We also decided that the Plan does not have to waive the coinsurance for the oxygen concentrators and
portable oxygen concentrators.
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 10%
coinsurance for the oxygen concentrators and the portable oxygen concentrators. See chart below.
Therefore, we decided that the Plan does not have to waive the coinsurance for the oxygen concentrators and
portable oxygen concentrators.
Date of Service Service Allowed Amount Coinsurance Member Liability
April 27, 2019 Oxygen
concentrator
$140.56 10% $14.06
May 27, 2019 Oxygen
concentrator
$140.56 10% $14.06
May 27, 2019 Portable oxygen
concentrator
$41.05 10% $4.11
June 27, 2019 Oxygen
concentrator
$140.56 10% $14.06
June 27, 2019 Portable oxygen
concentrator
$41.05 10% $4.11
July 27, 2019 Oxygen
concentrator
$140.56 10% $14.06
July 27, 2019 Portable oxygen
concentrator
$41.05 10% $4.11
August 27, 2019 Oxygen
concentrator
$140.56 10% $14.06
August 27, 2019 Portable oxygen
concentrator
$41.05 10% $4.11
September 27, 2019 Oxygen
concentrator
$140.56 10% $14.06
September 27,
2019
Portable oxygen
concentrator
$41.05 10% $4.11
October 27, 2019 Oxygen
concentrator
$135.00 10% $13.50
October 27, 2019 Portable oxygen
concentrator
$41.05 10% $4.11
November 27, 2019 Oxygen
concentrator
$135.00 10% $13.50
Date of Service Service Allowed Amount Coinsurance Member Liability
November 27, 2019 Portable oxygen
concentrator
$41.05 10% $4.11
December 27, 2019 Oxygen
concentrator
$135.00 10% $13.50
December 27, 2019 Portable oxygen
concentrator
$41.05 10% $4.11
Total $157.74