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). MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): a. The MA plan provides all categories of DME covered under original Medicare Part B; b. The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME products or brands; c. The MA plan's contracted suppliers provide access to all preferred DME brands; d. During an enrollee's first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and repairs, as applicable) non-preferred DME brands furnished in the previous year; e. Although the MA plan may add brands to its preferred formulary during the year, it may not remove any brands mid-year; f. The MA plan treats denials of non-preferred DME products or brands as organization determinations; g. The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred DME product or brand with the EOC and ANOC and on its website; and h. The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or subcategories annually determined by CMS to require full coverage.
You can find this information in Medicare Managed Care Manual Chapter 4 - Benefits and Beneficiary Protections, 10.12.2 - Specifying Brands or Manufacturers of DME (Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15) Contract suppliers are not required to furnish a specific brand name item or mode of delivery to a beneficiary unless prescribed by a physician or treating practitioner to avoid an adverse medical outcome. A physician or treating practitioner (that is a physician assistant, clinical nurse specialist, or nurse practitioner) may prescribe, in writing, a particular brand of a competitively bid item or mode of delivery for an item if he or she determines that the particular brand or mode of delivery is necessary to avoid an adverse medical outcome for the beneficiary. The physician or treating practitioner must document in the beneficiary's medical record the reason why the specific brand or mode of delivery is necessary to avoid an adverse medical outcome. You can find this information in Medicare Claims Processing Manual Chapter 36 - Competitive Bidding 30.4 - Prescription for Particular Brand, Item, or Mode of Delivery.
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 contract also says that diabetic test strips are limited to two specified manufacturers. You can find this information on page 70 of the Plan's 2021 Evidence of Coverage.