Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for ostomy supplies provided from January 
18, 2022, to March 24, 2022. 
 
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that the items are disposable and 
should not be billed as durable medical equipment. The Plan denied your request. The Plan says the correct 
coinsurance was applied. 
 
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 a 20% 
coinsurance for medical supplies, including ostomy supplies. 
 
 
 
 
 
 Item Allowed Amount 20% Coinsurance 
Skin Barrier (A4409)  January 18, 2022 $46.60 $9.32 
Drain Pouch (A4425)  January 18, 2022 $53.60 $10.72 
Pouch Deodorant (A4394)  January 18, 2022 $27.02 $5.40 
Skin Barrier Wipes (A5120)  January 18, 2022 $5.00 $1.00 
Skin Barrier (A4385)  January 18, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 19, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 20, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 21, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 22, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 23, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 24, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 25, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 26, 2022 $7.64 $1.53 
Skin Barrier (A4385)  January 27, 2022 $7.64 $1.53 
Pouch Deodorant (A4394)  February 14, 2022 $27.02 $5.40 
Drain Pouch (A4425)  February 14, 2022 $53.60 $10.72 
Skin Barrier Wipes (A5120)  February 14, 2022 $5.00 $1.00 
Skin Barrier (A4409)  February 14, 2022 $46.60 $9.32 
Skin Barrier (A4385)  February 14, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 15, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 16, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 17, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 18, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 19, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 20, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 21, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 22, 2022 $7.64 $1.53 
Skin Barrier (A4385)  February 23, 2022 $7.64 $1.53 
Pouch Deodorant (A4394)  March 15, 2022 $27.02 $5.40 
Drain Pouch (A4425)  March 15, 2022 $53.60 $10.72 
Skin Barrier Wipes (A5120)  March 15, 2022 $5.00 $1.00 
Skin Barrier (A4409)  March 15, 2022 $93.20 $18.64 
Adhesive Remover Wipes (A4456)  March 15, 2022 $10.50 $2.10 
Skin Barrier (A4385)  March 15, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 16, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 17, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 18, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 19, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 20, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 21, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 22, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 23, 2022 $7.64 $1.53 
Skin Barrier (A4385)  March 24, 2022 $7.64 $1.53 
Total:  $136.64 
 
You have been asked to pay a total of $136.64, which is 20% of the allowed amount for the ostomy supplies. 
The ostomy supplies 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 you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for ostomy supplies provided from 
January 18, 2022, to March 24, 2022.