Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
You asked the Plan to waive the cost-sharing for and pay for prosthetics. You say that your treating physician 
explained the medical reasons why these codes are so important and should be covered. The Plan says that the 
cost-sharing amounts you are being charged are correct. The Plan also says that the denial of payment for codes 
L5999 and L8499 is correct. 
 
We decided that the Plan has to pay for prosthetic codes L5999 and L8499.  
 
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. 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 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 specify whether the ordering physician was in-network or out-
of-network. The documentation submitted does not include prior notice from the Plan that these prosthetic 
evaluations/assessments and fiberglass reinforcement would not be covered. Your treating physician provided a 
statement supporting the necessity of these prosthetics. Without information regarding the physicians network 
status, we cannot determine whether the order made constituted plan-directed care. Therefore, the Plan has not 
shown that its decision to deny payment for codes L5999 and L8499 is correct or justified according to 
Medicare rules. Therefore, we decided that the Plan has to pay for prosthetic codes L5999 and L8499.  
 
We also decided that the Plan does not have to waive the cost-sharing for the covered prosthetics. 
 
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 $1,500 
deductible and 30% coinsurance for prosthetics. At the time these claims were processed, $0 of the $1,500 
deductible had been met. The allowed amounts of these claims total $11,398.99. You were asked to pay $1,000 
deductible, which is less than the $1,500 total deductible for your plan. After the deductible was applied, the 
remaining allowed amount is $10,398.99, but you have only been asked to pay $2,249.44 coinsurance amount 
which is less than 30% coinsurance. Your total cost-sharing amount is therefore $3,249.44.  
You have been asked to pay less than $1,500 deductible and less than 30% coinsurance for prosthetics. 
Prosthetics fall within the Prosthetic Devices and Related Supplies benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost-sharing is a contractual 
obligation that you agreed to when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the cost-sharing for and pay for prosthetics. 
 
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.