Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to waive the coinsurance for the oxygen equipment provided from August 15, 
2021, to December 15, 2021, and August 15, 2022, and September 15, 2022. We also decided that the Plan 
does not have to waive the coinsurance for the oxygen equipment provided from January 15, 2022, to July 15, 
2022.  
 
You asked the Plan to waive the coinsurance for the oxygen equipment. You say that you do not understand 
why the COVID-19 oxygen equipment is not covered at 100%. The Plan denied your request. The Plan says 
that the cost sharing amount was applied correctly. 
 
We decided that the Plan has to waive the coinsurance for the oxygen equipment provided from August 
15, 2021, to December 15, 2021, and August 15, 2022, and September 15, 2022.  
 
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 provide the 2021 EOC and the Explanation of Benefits (EOB) 
for dates of service August 15, 2021, September 15, 2021, August 15, 2022, and September 15, 2022. Without 
the 2021 EOC and the necessary EOBs we are unable to determine if the cost sharing was applied correctly. 
Therefore, we decided that the Plan has to waive the coinsurance for the oxygen equipment provided from 
August 15, 2021, to December 15, 2021, and August 15, 2022, and September 15, 2022.  
 
We also decided that the Plan does not have to waive the coinsurance for the oxygen equipment provided 
from January 15, 2022, to July 15, 2022.  
 
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 in-network durable medical equipment. 
 
The record shows these claims were approved and you are responsible for a cost share amount. You have been 
asked to pay $30.23, which is 20% coinsurance of the allowed amount for each oxygen concentrator provided 
from January 15, 2022, to July 15, 2022 ($151.15 allowed amount x 20% coinsurance = $30.23). You have also 
been asked to pay $5.39, which is 20% coinsurance of the allowed amount for the portable oxygen systems 
provided on June 15, 2022, and July 15, 2022 ($26.96 allowed amount x 20% coinsurance = $5.39). These 
items/services fall within the durable medical equipment 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 the oxygen equipment provided from January 15, 2022, to July 15, 2022. 
 
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.