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 say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 

The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).

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 health plan contract says that if you are diagnosed with the following chronic condition(s) identified below and meet certain criteria, you may be eligible for special supplemental benefits for the chronically ill:

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 venous thromboembolic 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, Major depressive 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 
15. Stroke 
16. Chrohn's disease 
17. Ulcerative colitis 
18. Anemia 
19. Chronic obstructive pulmonary disease 
20. Severe mental retardation 
21. Moderate to severe autism

You can find this information on page 66 and 67 of the 2021 Evidence of Coverage. 

The health plan contract says that for new members, you must have one or more of the aforementioned conditions, you must also have a high risk of hospitalization or other adverse health outcomes, and you must require intensive care coordination. We will validate your condition and confirm your eligibility. Remember, you must remain a member of the plan and meet all the eligibility criteria mentioned above to continue to be eligible for these benefits. If you are a current member, your condition and eligibility criteria will be confirmed through the information we have in our system that makes you eligible. You can find this information on page 67 of the 2021 Evidence of Coverage.