Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for the wheel lock assembly replacement which was denied and applied in 
full to your liability. We decided that the Plan does not have to waive the coinsurance amounts for the wheel 
lock assembly replacement and repair or non-routine service for durable medical equipment.  
 
You asked the Plan to waive the cost share amounts for the wheel lock assembly replacement (E2206) and 
repair or non-routine service for durable medical equipment (K0739) provided on February 7, 2023. You also 
asked the Plan to pay for a wheel lock assembly replacement (E2206) provided on February 7, 2023 which 
denied and was applied in full to your liability. You say that you told the provider that if you were billed for the 
repairs in February 2023, you would file a grievance. The Plan says that this cost sharing was charged 
correctly. 
 
We decided that the Plan has to pay for the wheel lock assembly replacement which was denied and 
applied in full to your liability.  
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You were referred for one wheel lock assembly replacement by a contract provider. The file does not show that 
the Plan provided notice that one wheel lock assembly replacement would not be covered. Under Medicare 
rules, this means one wheel lock assembly replacement is considered approved by the Plan. Therefore, we 
decided that the Plan has to pay for the wheel lock assembly replacement which was denied and applied in full 
to your liability.  
 
We also decided that the Plan does not have to waive the coinsurance amounts for the wheel lock 
assembly replacement and repair or non-routine service for durable medical equipment. 
 
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 15% 
coinsurance for Durable Medical Equipment.  
 
You have been asked to pay 15% coinsurance for one wheel lock assembly replacement and repair or non-
routine service for durable medical equipment. These items fall within the Durable Medical Equipment 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 coinsurance amounts for the wheel lock assembly replacement 
and repair or non-routine service for durable medical equipment. 
 
  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.