Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diabetic supplies provided from January 
12, 2023, to September 15, 2023. 
 
You asked the Plan to waive the copayment for the diabetic supplies. You say that you should not have to pay 
the cost share for your diabetic 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% 
coinsurance for Medicare-covered equipment and supplies. 
 
You have been asked to pay a total of  $326.35 for the diabetic supplies.  
 
The total amount allowed to be billed for diabetic supplies provided on January 12, 2023, was $112.50. You 
have been asked to pay an $22.50 coinsurance for these services, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for diabetic supplies provided on February 11, 2023, was $112.50. You 
have been asked to pay an $22.50 coinsurance for these services, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for diabetic supplies provided on March 13, 2023, was $112.50. You 
have been asked to pay an $22.50 coinsurance for these services, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for diabetic supplies provided on April 12, 2023, was $112.50. You have 
been asked to pay an $22.50 coinsurance for these services, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for diabetic supplies provided on May 12, 2023, was $236.34. You have 
been asked to pay an $47.27 coinsurance for these services, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for diabetic supplies provided on June 11, 2023, was $236.34. You have 
been asked to pay an $47.27 coinsurance for these services, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for diabetic supplies provided on July 17, 2023, was $236.34. You have 
been asked to pay an $47.27 coinsurance for these services, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for diabetic supplies provided on August 16, 2023, was $236.34. You 
have been asked to pay an $47.27 coinsurance for these services, which is 20% of the total allowed amount. 
 
The total amount allowed to be billed for diabetic supplies provided on September 15, 2023, was $236.34. You 
have been asked to pay an $47.27 coinsurance for these services, which is 20% of the total allowed amount. 
 
This items 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 to waive the copayment for the diabetic supplies provided from January 12, 2023, to September 
15, 2023.