Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have pay more for the catheters and supplies provided on January 1, 2022, to 
August 31, 2022. 
 
You asked the Plan pay more for the catheters and supplies. You say that you should be reimbursed for the 
catheters and supplies. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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% 
for Medicare-covered equipment and supplies.  
 
  You have been asked to pay a total of $373.68 for the catheters and supplies. 
 
The total amount allowed to be billed for catheter and supplies provided on November 16, 2022, was $379.50 
($937.50 - $558 = $379.50). You have been asked to pay an $75.90 coinsurance, which is 20% of the total 
allowed amount. 
 
The total amount allowed to be billed for catheter and supplies provided on November 17, 2022, was $83.70 
($213.50 - $129.80 = $83.70). You have been asked to pay an $16.74 coinsurance, which is 20% of the total 
allowed amount. 
 
The total amount allowed to be billed for catheter and supplies provided on December 15, 2022, was $7.80 
($26 - $18.20 = $7.80). You have been asked to pay an $1.56 coinsurance, which is 20% of the total allowed 
amount. 
 
The total amount allowed to be billed for catheter and supplies provided on January 18, 2023, was $7.80  
($26 - $18.20 = $7.80). You have been asked to pay an $1.56 coinsurance, which is 20% of the total allowed 
amount. 
 
The total amount allowed to be billed for catheter and supplies provided on February 13, 2023, was $534.60 
($990 - $455.40 = $534.60). You have been aske to pay an $91.08 coinsurance, which is less than the 20% 
coinsurance. 
 
The total amount allowed to be billed for catheter and supplies provided on February 17, 2023, was $7.80  
($26 - $18.20 = $7.80). You have been asked to pay an $1.56 coinsurance, which is 20% of the total allowed 
amount. 
 
The total amount allowed to be billed for catheter and supplies provided on April 3, 2023, was $129.80 
($213.50 - $83.70 = $129.80). You have been asked to pay an $16.74 coinsurance, which is less than the 20% 
coinsurance. 
 
The total amount allowed to be billed for catheter and supplies provided on April 3, 2023, was $379.50 
($937.50 - $558 = $379.50). You have been asked to pay an $75.90 coinsurance, which is 20% of the total 
allowed amount. 
 
The total amount allowed to be billed for catheter and supplies provided on May 1, 2023, was $534.60 
($990 - $455.40 = $534.60). You have been asked to pay an $91.08 coinsurance, which is less than the 20% 
coinsurance. 
 
The total amount allowed to be billed for catheter and supplies provided on June 6, 2023, was $7.80  
($26 - $18.20 = $7.80). You have been asked to pay an $1.56 coinsurance, which is 20% of the total allowed 
amount. 
 
These items/services fall within the durable medical equipment (DME) 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 pay more for the catheters and supplies provided on January 1, 2022, to August 31, 
2022.