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 a Medicare plan may restrict members to a network of providers as long as medically
necessary covered care is accessible and available through the network. The rules say that the Plan must
arrange for specialty care outside of the Plan provider network when network providers are unavailable or
inadequate to meet a member's medical needs. You can find this rule at 42 CFR Section 422.112(a)(3).

The rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing
for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands
and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)):

- The MA plan provides all categories of DME covered under original Medicare Part B;
- The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME
products or brands;
- The MA plan's contracted suppliers provide access to all preferred DME brands;
- 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;
- Although the MA plan may add brands to its preferred formulary during the year, it may not remove any
brands mid-year;
- The MA plan treats denials of non-preferred DME products or brands as organization determinations;
- 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 Evidence of Coverage and Annual Notice of Change and on its website; and
- 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 the Centers for Medicare and Medicaid Services (CMS) Medicare Managed
Care Manual Chapter 4, Section 10.12.2- Specifying Brands or Manufacturers of DME.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that, with limited exceptions, members of the Plan must use network providers to get
medical care and equipment. The only exceptions are emergencies, urgently needed care when the network is
not available (generally, when the enrollee is out of the area), out-of-area dialysis services, and cases in which
the Plan authorizes the use of out-of-network providers. You can find this information on page 12 of the Plans
2021 Evidence of Coverage.

The Plan contract says that for durable medical equipment, the Plan will not cover specific brands and
manufacturers unless your doctor or other provider indicates the brand is appropriate for your medical needs.
You can see this on page 63 of the Plans 2021 Evidence of Coverage.