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 effective for claims with dates of service on or after January 12, 2017, Medicare covers therapeutic Continuous Glucose Monitor (CGM) devices under the Durable Medical Equipment (DME) benefit. CGM devices covered by Medicare are defined in CMS Ruling 1682R as therapeutic CGM. CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit). There is no Medicare benefit for supplies and accessories used with equipment that is not classified as DME. Coverage of a CGM system supply allowance (K0553) is available for those therapeutic CGM systems where the beneficiary uses a receiver classified as DME to display glucose data. You can find this information in the Local Coverage Article: Glucose Monitor - Policy Article (A52464).  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 the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that the Plan covers any blood glucose monitors and test strips specified within this list (Accu-check and OneTouch). We will generally not cover alternate brands unless your doctor or other provider tells us that use of an alternate brand is medically necessary in your specific situation. You can find this information on page 4-15 to 4-16 pf the Plan's 2021 Evidence of Coverage.