Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules state that a supplemental benefit is an item or service not covered by original Medicare, that is 
primarily health related and for which the MA plan must incur a non-zero direct medical cost. These criteria are 
defined below. 
(1) A supplemental benefit may not be a Medicare Part A or Part B covered service; 
(2) The item or service must be primarily health related; that is, the primary purpose of the item or service is to 
prevent, cure or diminish an illness or injury. If the primary purpose of the item or service is comfort, cosmetic 
or daily maintenance, then it is not eligible as a supplemental benefit. The primary purpose of an item or 
service is determined by national typical usages of most people using the item or service, or by community 
patterns of care; and  
(3) The MA plan must incur a non-zero direct medical cost in providing the benefit. If the MA plan only incurs 
an administrative cost, this requirement is not met.  
An item or service that meets the above three conditions may be proposed as a supplemental benefit in an MA 
plan's bid and submitted plan benefit package. You can find this rule in the Medicare Managed Care Manual, 
Chapter 4, Section 30. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract states that if you have been diagnosed by a qualified provider with certain chronic conditions and you 
meet certain criteria, you may be eligible for additional benefits. To be eligible for these additional benefits, 
you must meet the following requirements: You must have one or more comorbid and medically complex 
chronic conditions that are life-threatening or significantly limit your health or general functioning -see the list 
of applicable conditions below. In addition, you must have a high risk of hospitalization or other adverse health 
outcomes; and must require intensive care coordination. 
Eligible chronic conditions: 
1. Chronic alcohol and other drug dependence;  
2. Autoimmune disorders limited to: Polyarteritis nodosa, Polymyalgia rheumatica, Polymyositis,  Rheumatoid 
arthritis, and  Systemic lupus erythematosus;  
3. Cancer, excluding pre-cancer conditions or in-situ status; 
 4. Cardiovascular disorders limited to: Cardiac arrhythmias, Coronary artery disease, Peripheral vascular 
disease, and Chronic venous thromboembolic disorder;  
5. Chronic heart failure; 
6. Dementia;  
7. Diabetes mellitus;  
8. End-stage liver disease;  
9. End-stage renal disease (ESRD) requiring dialysis;  
10. Severe hematologic disorders limited to: Aplastic anemia, Hemophilia, Immune thrombocytopenic purpura, 
Myelodysplatic syndrome, Sickle-cell disease (excluding sickle-cell trait), and Chronic venousthromboembolic 
disorder;  
11. HIV/AIDS;  
12. Chronic lung disorders limited to: Asthma, Chronic bronchitis, Emphysema, Pulmonary fibrosis, and 
Pulmonary hypertension;  
13. Chronic and disabling mental health conditions limited to: Bipolar disorders, Majordepressive disorders, 
Paranoid disorder, Schizophrenia, and Schizoaffective disorder;  
14. Neurologic disorders limited to:  Amyotrophic lateral sclerosis (ALS), Epilepsy, Extensive paralysis (i.e., 
hemiplegia, quadriplegia, paraplegia, monoplegia), Huntington?s disease, Multiple sclerosis, Parkinson's 
disease, Polyneuropathy, Spinal stenosis, and Stroke-related neurologic deficit; and  
15. Stroke. 
You can find this information on pages 110 to 114.