Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the hearing aids (V5261). We decided that the Plan does not have to 
waive the coinsurance for the acoustic immittance testing (92570) and distortion product evoked otoacoustic 
emissions (92588).  
 
You asked the Plan to pay for the hearing aids (V5261), and to waive the coinsurance for the acoustic 
immittance testing (92570), and distortion product evoked otoacoustic emissions (92588) provided on March 2, 
2022. You say that you went to this doctor to be treated for a ruptured ear drum that another did. You also say 
that you need your hearing aids very bad because you are having a hard time without them. The Plan says that 
the claim was processed as you pay 20% of the total amount for services from an in-network or out-of-network 
provider. 
 
We decided that the Plan has to pay for the hearing aids (V5261).  
 
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 2022 Schedule of Cost Sharing states that the Plan will reimburse you up to 
$3,000 once every 60 months towards the cost of hearing aids. The record shows that you received hearing 
aids, but the Plan does not offer any explanation as to why the hearing aids were denied. You reasonably 
believed that the hearing aids would be covered per your contract with the Plan. Therefore, the Plan has not 
substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the hearing 
aids (V5261).  
 
  We also decided that the Plan does not have to waive the coinsurance for the acoustic immittance testing 
(92570) and distortion product evoked otoacoustic emissions (92588). 
 
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 each Medicare-covered diagnostic procedure and test under the Outpatient diagnostic tests and 
therapeutic services and supplies benefit category. 
 
You have been asked to pay a 20% coinsurance for the acoustic immittance testing (92570) and distortion 
product evoked otoacoustic emissions (92588). These services fall within the Outpatient diagnostic tests and 
therapeutic services and 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 
the acoustic immittance testing (92570) and distortion product evoked otoacoustic emissions (92588). 
 
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. 
 
 
Your complaint about the treating provider not taking an impression of your ears, filing a claim without your 
knowledge, and the treating provider committing possible fraud/stealing is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.