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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 a Medicare plan may not pay for services given by a physician or other practitioner who has
opted out of Medicare. This rule does not apply to emergency or urgently needed services. This rule applies to
all other services, as well as to supplemental benefits. A Medicare plan must pay for emergency or urgently
needed services given by a physician or practitioner who has not signed a private contract with the enrollee.
You can find these rules at 42 CFR Sections 422.102 and 422.220 and in the Medicare Managed Care Manual,
Chapter 6, Section 60.2.
The rules say that with the exception of the situations described above, orthopedic footwear billed using codes
L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100,
L3140, L3150, L3160, L3170, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212,
L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252,
L3253, L3254, L3255, L3257, L3260, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350,
L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470,
L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600,
L3610 ,L3620, L3630, L3640, and L3649 will be denied as noncovered. You can find this information in
Medicare's Local Coverage Article: Orthopedic Footwear - Policy Article (A52481).
Medicare guidelines say Medicare will only cover durable medical equipment (DME) if your doctors and DME
supplies are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay
enrolled in Medicare. If your doctor's or suppliers aren't enrolled, Medicare will not pay the claims submitted
by them. It is important to ask you supplies if they participate in Medicare before you get DME. To find
supplies who accept Medicare assignment visit: Medicare.gov/supplierdirectory or call 1-800-MEDICARE (1-
800-633-4227). You can find this guidance at the Medicare website: https://www.cms.gov, under durable
medical equipment and the 2019 Medicare & You brochure on page 37.
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
benefits say the plan must cover all services covered by Original Medicare and must follow Original
Medicare's coverage rules. The plan will generally cover your medical care as long as the care you receive is
included in the plan's Medical Benefits Chart in Chapter 4 of your Evidence of Coverage and you received the
care form a provider is eligible to provide services under Original Medicare. While you can get care form outof-
network providers, the providers must be eligible to participate with Medicare. If you go to a provider who
is not eligible to participate, you will be responsible for the full cost of the services you received. You can find
this guidance in your 2019 Evidence of Coverage, Chapter 3, Section 1.2 on pages 3-2 and 3-3.